Cervical-Throacic Evaluation and
Treatment
Development of a Clinical Prediction
Rule
Tara Jo Manal PT, DPT, OCS, SCS
Greg Hicks PT, PhD
University of Delaware
Special Tests

Debate in the meaningfulness and
usefulness of Vertebral Artery Testing

? Interpretation of a negative test

If positive, further evaluation is indicated
University of Delaware
Vertebral Artery Test


Combined Movements
to stress test the
cervical spine
Symptoms:
–
–
–
–
–
Dizziness -Tinnitus
Lightheadedness
Nystagmus -Parathesia
Dysarthria - Diplopia
Dysphagia
University of Delaware
Vertebral Artery Preliminary Test
Patient is sitting. Sustain cervical extension
for 10 seconds.
 Sustain Rotation (L and R) 10 seconds
 IF POSITIVE STOP
 If the testing is negative progress to
standard position.

University of Delaware
Vertebral Artery Standard Test
Patient is supine. Sustain cervical extension
for 10 seconds.
 Sustain Rotation (L and R) for 10 seconds
 Combine Extension with Rotation (L and R)
for 10 seconds.
 Test the patient in the manipulation
position
 IF POSITIVE STOP, do not manipulate

University of Delaware
Cervical Distraction

Nerve Root
Compression

Radicular pain is
decreased, test is
positive
University of Delaware
Cervical Compression Test

Pressure downward on
head

Test is positive if pain
is evoked
University of Delaware
Spurling A




Seated
Neck Side bent to the
ipisilateral side
7kg of overpressure
applied
Presence of pain,
parasthesial or
numbness
University of Delaware
Spurling B




Seated
Extension
Sidebending and
Rotation to the
ipsilateral side
7kg of axial pressure
is applied
University of Delaware
Sharp –Purser Test





Neck in semi flexion
Palm of one hand on
forehead
Index finger on
Spinous process C2
Posterior force
through forehead
Posterior slide is + for
AA instability
University of Delaware
Shoulder Abduction Sign


Most common nerve
root compression at
C5-6
Decrease in symptoms
is positive response
University of Delaware
Median Nerve Testing







Shoulder Retraction
and Depression
Shoulder Extension
External Rotation
Elbow Extension
Forearm Supination
Wrist/Finger
Extension
Cervical SB and Rot
Away
University of Delaware
Upper Limb Tension Testing A






Scapular Depression
Shoulder Abduction
Shoulder ER
Elbow Extension
Forearm Sup
Wrist and Finger
Extension
University of Delaware
Radial Nerve Testing






Proximal as for
Median
Shoulder Internal Rot
Forearm Pronation
Wrist Flexion
Ulnar Deviation
Finger Flexion
University of Delaware
Upper Limb Tension Testing B






Supine in 30º Abd
Scap Depression
Shoulder IR
Elbow Extension
Wrist and Finger
Flexion
Opposite Cervical SB
and Rot
University of Delaware
Ulnar Nerve Testing







Shoulder Retraction
Shld Ext and ER
Elbow Flexion
Forearm Supination
Wrist Extension and
Radial Deviation
Finger Extension
Cervical SB and Rot
away
University of Delaware
T1 Nerve Root Stretch




Abduct to 90º
Flex pronated arms to
90º
Flex elbows and place
behind the neck
Pain in scapular area is
T1- Pain in Ulnar
distribution is Ulnar
University of Delaware
Thoracic Outlet

Roos Test
– Standing Abduct arm
to 90°
– ER shoulder
– Open and Close hand
for 3 minutes

Positive if unable to
maintain position or
heaviness/tingling in
arm
University of Delaware
Thoracic Outlet






Adson Maneuver
Supine
Palpate Radial Pulse
Abduct, Extend and
ER arm
Take deep breath and
rotate toward arm
+ Subclavian if change
in radial pulse
University of Delaware
Thoracic Outlet




Halstead Maneuver
Palpate radial pulse
and distract UE
Patient extends and
rotates cervical spine
to opposite side
Positive for TOS if
absence of pluse
University of Delaware
Cervical Evaluation
Tara Jo Manal PT, DPT, OCS, SCS
Greg Hicks PT, PhD
University of Delaware
Determining Severity

Stage 1
– Inability to perform basic mechanical functions
» Stand for 15 minutes
» Sit for 15 minutes
» Walk greater than ¼ mile
– Cervical Oswestry (NDI) ≥ 30%
» Often as high as 50% (less than 2 wks otherwise r/o
symptom magnification)
– Tx- Pain modulation and movement
University of Delaware
Stage 1 Treatment
Joint Manipulation\Mobilization
 Traction
 Active Spinal Movement
 Sleeping Postures
 NSAIDS
 Physical Agents
 Cervical Collar (rest from function only)

University of Delaware
Determining Severity

Stage II
– Unable to carry out ADL’s
» Vacuum, lift, push, pull
– Oswestry (NDI) 20-30%

Treatment
–
–
–
–
–
Weakness
Tightness
Posture
Body Mechanics
Active Exercise
University of Delaware
Determining Severity

Stage III
– Can perform ADL’s and high demand for brief time
periods
– Cannot return fully to high demand activities
» Sports, occupational duties, deconditioned
– Cervical Oswestry(NDI) ≤ 20%

Treatment- Return to work/play
– Ergonomic Assessment/Modifications
– Endurance
University of Delaware
Assessment of Movement

Cyriax Capsular Pattern
– Full flexion, limited extension and
symmetrically limited rotation and sidebending
– Arthritis, inflammation or DJD of the joints
– Flexion is not significantly involved since the
neck tolerates flexion well
– Restricted flexion
» Upper Thoracic and Cervicothoracic junction
University of Delaware
Range of Motion




Flexion
Extension
Sidebending
Rotation
–
–
–
–

Note quantity
Quality (deviations/location)
Symptom provocation
Active and Passive overpressure
Clear the shoulder (pain free ROM)
University of Delaware
Non capsular pattern

Flexion is limited (non capsular)
– Often cervicothoracic or upper thoracic jxn
Opening Restrictions
 Closing Restrictions
 Combination Restrictions

– Significant dysfunction
– Located 2 or more areas
– Compensations
University of Delaware
Referred Symptoms

Closing Restriction
– Extension and Sidebending reproduce sx’s

Limited Cervical Flexion and symptoms
– Not typical decreased cervical flexion with
symptoms in upper back

Sidebending to opposite side produces distal
symptoms
University of Delaware
Upper Quarter Screen
Spurling’s
 Hoffman’s Reflex (Babinski of UE)
 L’hermittes
 Reflexes
 MMT
 Sensory Testing

University of Delaware
Consider Disc
True limitation in cervical flexion
 Radiculopathy recreated with motion
 Neurological findings

– Refer for MRI
University of Delaware
Cervical Evaluation
Passive Range of Motion with endfeel
 Joint Play

–
–
–
–
Central PA glides
Prone unilateral PA’s (facet glides)
Supine downglides
Can perform in Neutral, Flexion and Extension
University of Delaware
University of Delaware
Response to Range of Motion
Capsular Pattern (No Radiculopathy)?
Yes
Determine Stage and Treat
•Stage I Mobs, Traction, Modalities, NSAIDS, Sleeping
Postures
•Stage II Active Exercise, Postural Correction, Daily
Activities
•Stage III Ergonomic Assessment and Modifications
University of Delaware
Response to ROM
No Capsular Pattern
Is Flexion Limited?
No
Yes
Assess and Tx
Is there an opening Restriction?
C-T and T jxn
Yes
No
Joint Mobs for opening
Is there a Closing Restriction?
Yes
University of Delaware
Joint Mobs for closing
No
Likely a combined lesion
Limited Forward Flexion
Traction Manip to C-T Junction and Thoracic
Full Passive Flexion
Forward Flexion Still Limited
(see next)
Try Cervical Traction
University of Delaware
Improve:
No Change:
Continue
MRI for mechanical block
Full Flexion
Opening Restriction
No Radicular SXs during movement
Radicular SXs during movement
Opening
Manipulation
-TOS signs
Traction Manipulation
+Radicular SXs on Opening
University of Delaware
ICT
+TOS signs
Joint Mobs for opening
-Radicular SXs on Opening
Opening Manipulation
Upper Thoracic Manipulation





CT junction
Patient sits far back on
table
Stabilize shoulders
Use their hands as
fulcrum
Distract upwards
– Drop down
University of Delaware
Thoracic Outlet


Clavicle, 1st Rib and
Costoclavicular lig,
subclavius and ant
scalene
Compression of
subclavian or axiallary
artery, vein, or
brachial plexius (C8
and T1)
University of Delaware

Costoclavicular
syndrome
– Loss space between
clavicle and 1st rib

Cervical Rib (<1%)
syndrome
– Cervical rib from C7 or
band of fibrous tissue
in area
Thoracic Outlet

Anterior Scalene
Syndrome
– Compression of
neurovascular bundle
between anterior and
middle scales
– Tingling 4th and 5th
digit
– Ulnar and Median
weakness
– If vascular hand edema
University of Delaware



Testing should
recreate symptoms
Vascular change alone
is not predictive
Exacerbated by
shoulder
hypermobility
– Dead arm
Full Flexion and Closing Restriction
No Radicular Symptoms on closing
Closing Manipulation
University of Delaware
Full Flexion and Closing Restriction
Radicular symptoms on closing
+ Neuro Signs
Traction Manip
- Neuro Signs
Opening Manip
+ Radicular
-Radicular
+ Radicular
- Radicular
with Closing
with Closing
with Closing
with Closing
Traction Manip
Closing Manip
ICT
University of Delaware Closing Manip
Early Treatment for Pain

3 Finger Treatments- Painfree ROM
– Neck Retraction
– Lateral Flexion
– Rotation

Decrease flexion (increase fingers) as pain subsides
University of Delaware
Early Treatment for Pain

Rest
– Throughout day, interrupt activity

Supported Sleep
– Butterfly pillow (good cervical pillow)

Upright Posture
– Avoid hanging head
– Collar As Needed
University of Delaware
Stage II Treatment

Improve Range
– Joints, muscles, neural tissue

Improve Stability
– Strengthen weak muscles
– Improved Postural Control

Improve Aerobic Capacity
– Activity endurance
University of Delaware
Self Stretching/Joint Mobs
Use hands to stabilize cervical spine
 SNAG’s with towel

University of Delaware
University of Delaware
Indication for Cervical
Manipulation
Most successful in presence of a specific
restriction (primarily mechanical block)
 T Tenderness
 A Asymmetry
 R Restriction of Movement
 T Tension (muscle and soft tissue)
Bourdillon 1970

University of Delaware
Differential Diagnosis

History
– Fracture or Instability
– Index of Suspicion
Intoxication, LOC, High Energy Injuries
– x-rays
lateral(flex/ext),AP,open mouth,obliques
– Osteophytic Encroachment
– Whiplash(acceleration injury)
University of Delaware
Contraindications to
Manipulation
Paget’s Disease
 Rheumatoid Arthritis
 Osetomyelitis
 Ankylosing Spondylitis
 Malignancy
 Cord and Cauda Equina Syndrome
 Vertebral Artery Involvement

University of Delaware
Complications Due to
Manipulation





Neurovascular Complications
Author
Cases
Sherman, Smialek &Zane
52
Grant
58
Patijin
84
Terrett
107
Kunnasmaa & Thiel
139
(Rivett, Milburn 1996)
University of Delaware
Lee et al. Neurology 1995
Survey of 177 Neurologists
 Report of neurologic complications
following chiropractic manipulation
 102 Complications
56 Strokes
13 Myelopathies
22 Radiculopathies

University of Delaware
Hurtwitz et al. 1996 Spine
 Complication Rate

– 5-10 in 5 to 10 million
– Less than 120 cases in English
» Primarily Vertebrobasilar accident (VBA)

Brain stem or cerebellar infarct
» Cord compression, Fracture, Tracheal rupture
» Diaphragm paralysis, carotid hematoma or cardiac
arrest
University of Delaware
Injury on 118 Complications
Initial Complaints
 37 (31.5%) Neck Pain
 10 (8.5%) Neck stiffness
 17 (14.5%) Head and neck pain or stiffness
 23 (19.5%) Headaches
 31 (26%) Other

– Torticollis, back pain, head colds
University of Delaware
Injury in Manipulation
82% were rotational manipulations
 66% had signs or symptoms of VBA

– After first manipulation

78% had consequences of VB ischemia
– 20 died
– 42 had residual symptoms
Risk for Mild complication 1 in 40,000
 Risk for Serious complication 1 in 1 million

University of Delaware
Complications Resulting from
Treatments of the C-spine

Treatment
Manipulation
Complication
VBA, Major
Complication or Death
– 5-10/10,000,000

Cervical Surgery
– 15.6/1000
– 6.9/1000

NSAIDS
Neurological Compromise
Death
Serious GI event
3.2/1000 (age 65+)
Bleeding, perforation, or other
.39/1000 (<65)
resulting in hospitalization or death
1/1000 (Ages combined)
University of Delaware
Examination

Perform an Upper Quarter Screen
– Check dermatomes
– Check myotomes
– Check reflexes
University of Delaware
Range of Motion

Cervical spine facet motion
– Flexion causes facet opening
– Extension causes facet closing
– Rotation and Lateral Flexion(SB) occur in the
same direction
– Rotation and Lateral Flexion cause facet
opening contralerally and closing ipsilaterally
University of Delaware
Cervical Facet Opening/Closing

Maximal Left Opening
– Forward Flexion
– Right Rotation
– Right Sidebending
University of Delaware

Maximal Left Closing
– Extension
– Left Rotation
– Left Sidebending
Treatment/Manipulation

To Open or Close?
– Force a stuck drawer close
– Open the drawer fully and then attempt to close
it
University of Delaware
Cervical Manipulation Procedure







Position patient comfortably
Palpate the cervical treatment level
Flex or Extend the neck until
tension/approximation is noted at the spinal
interspace above the desired level
Rotate the head to end range
During patient exhalation - stress end range
Quickly overpress when the patient relaxes
Reassess the patient’s movement and record
University of Delaware
Manipulation Position for Right
Cervical Closing
University of Delaware
Alternative to Manipulation

Follow the outlined treatment(no overpress)
– Oscillate the head at end range
Traction (manual or mechanical)
 Soft tissue Treatment

– Modalities
– Massage
Seek training with skilled manipulator
 Refer patient to skilled manipulator

University of Delaware
Myth of Manipulation

Manipulation is not
– Dealing with dislocation/subluxation
– Correcting a “little bone out of place”
– Restoring a “slipped disc”

Manipulation is
– Designed to overcome a motion restriction
University of Delaware
Cervical Radiculopathy
University of Delaware
Cervical Case
University of Delaware
Reliability and Accuracy of
Clinical Exam for Cervical
Radiculopathy
Wainner Spine 2003
 82 Patients with suspected Cervical
radiculopathy or carpel tunnel
 Electrophysiological Testing

– Nerve Conduction Study
– Needle Electromyography

Clinical Exam
– 34 items and 2 raters
University of Delaware
Wainner Spine 2003

Data Collected
–
–
–
–
–
–
–
Visual Analog Scale
NDI
History Questions
MMT of Upper Quarter
Reflexes
Pin prick sensation
Cervical ROM
» 2 warm up- 1 trial with inclinometer
University of Delaware
Provocative Tests

Induce or alleviate mechanical pressure
Enlarge neural foramen
 Stretch or slacken neural elements
 Increase intrathecal pressure

University of Delaware
Wainner Spine 2003

Provocative Testing
–
–
–
–
–
–
Spurling A
Spurling B
Shoulder Abduction Test
Valsalva Maneuver
Neck Distraction
Upper Limb Tension A and B
University of Delaware
Cervical Radiculopathy
Upper Limb Tension Test A (symptoms
recreated, ≥10° elbow ext. difference or
wrist flexion, cervical SB’ing increases sx.)
 Involved Cervical Rotation less than 60
degrees
 Distraction Test (Supine examiner distractssymptoms reduced)
 Spurling A (Sidebend with compression)

University of Delaware
Cervical Radiculopathy




Upper Limb Tension Test A
Involved Cervical Rotation of less than 60°
Distraction Test (Reduces symptoms)
Spurling A
– ( if negative best to rule out)


2 Tests = 21%
4 Tests= 90%
3 tests= 65%
Reference Criterion- Electrophysiological Testing
University of Delaware
Radiculopathy Treatment
Cleland JOSPT 2005
 Diagnosis based on Wainner et al.

Case Series of 10 patients
 6 month Follow up

University of Delaware
Subjects
11 of 28 satisfied criteria
 Age =  51.7 (S.D. 8.2)
 Symptom Duration=  18 weeks (8-52)
 Treatments =  7.1 (6-10)
 9 of 11 had neck & upper extremity pain(82%)

University of Delaware
Treatment


Cervical and Thoracic Mobilizations
Deep neck flexor
– Supine flattening cervical lordosis with nod
– 10 second hold/ 10 reps

Scapular exercises
– Middle and Lower trap (prone on plinth)
– Serratus Wall push ups

Mechanical traction to centralize or reduce sx’s
– Intermittent 30:10 for 15 minutes
– 8.2 kg (18lbs) increased .5-1kg/visit
University of Delaware
Cervical Lateral Glides
University of Delaware
Thoracic Manipulations
University of Delaware
Outcomes

Discharge: 8 of 11 (73%) were negative on cluster
of tests
– 2 had positive Spurling’s but improved function
– 1 had ULTT and Suprling’s

10 Patients (91%) had clinically meaningful
reductions in pain and disability
– (> 2-7pt change)
– Lasted for 6 months» 45 % had 10/10
» 50% had mild limitations
University of Delaware
Expand Criteria

If treatment aimed at thoracic helps with
radiculopathy- how about neck pain?
University of Delaware
Subjects

Primary Complaint of Mechanical Neck
Pain
– Nonspecific pain in cervicothoracic jxn
worsened with neck movements
NDI
 VAS (0-100)
 36 subjects

University of Delaware
Randomized Treatment

Thoracic manipulation

Sham Manipulation
University of Delaware
Immediate Response to
Manipulation
University of Delaware
Clinical Prediction Rule
Which patients with neck pain can benefit
from thoracic manipulation, exercise, and
patient education?
 Cleland et al. Physical Therapy 2007

University of Delaware
Clinical Prediction Rule for Neck
Pain




Age- 18-60
Neck pain with and
without unilateral arm
symptoms
NDI > 10%
Exclusions: Red flags,
whiplash < 6 weeks,
cervical spinal stenosis,
CNS problem
– 2 signs of nerve root
myotomes, sensation,
reflexes
University of Delaware




Numeric Pain Rating
NDI and FABQ
Distal symptom local
Various measurements
–
–
–
–
–
Neurological Screen
Postural assessment
Cervical ROM
Joint Mobility
Strength/endurance of
muscles
– Spurlings, Roos,
Distraction, ULTT
University of Delaware
Intervention

3 Thrust
Manipulations
– 2 reps of each

Seated Distraction
University of Delaware
Intervention

Supine Upper
Thoracic Manip
University of Delaware
Intervention

Supine Middle
Thoracic Manipulation
University of Delaware
Other Intervention

Cervical ROM
University of Delaware
Outcomes

Greater than +5 point
change on global rating of
change

If not achieved after
treatment 1, repeated on
next treatment

No +5 after 2 treatments=
Non Responder
University of Delaware
University of Delaware