Lesson 7
Mid Cervical Spine
Assessment and Treatment
Rotation / Side Bend
Arthrokinematics
Sidebend /rotation
U joints/ Z jts
ipsi
inf, med, post
( IMP)
contra sup,ant, lat
( SAL)
Mean Values and ranges of axial
rotation of cervical motion segments
CT scanning Penning , Wilmink 87
Segment
ROM
Mean
Range
C3-4
6.5
3-10
C4-5
6.8
2-12
C5-6
6.9
0-12
C6-7
2.1
2-10
C7-T1
2.1
-2-7
Normal ROM in axial rotation and
coupled motion – biplanar
radiography Mimura’89
Segment Axial
rotation
SD
C3-4
6 ( 5)
Flex/ext
SD
Lateral
flexion SD
-3( 5)
6( 7)
-2( 4)
6( 7)
C4-5
4 (6)
C5-6
5( 4)
2(3)
4( 8)
C6-7
6(3)
3( 3)
3( 7)
Objective Assessment
• Active ROM – upper vs mid cervical
• Repeated Movement
• Habitual and Combined Movements
Joint Play Movements
• Central PA C3-7 – what does it tell
you?
• Central Angle Caudally – what
movement ?
• Unilateral PA 3-7 – incline cranially and
caudally
Passive Segmental Tests
PPIVMS
• Used to determine the amount and quality of
passive physiological movement available at
a motion segment
• Flexion, Extension, Side bending/rotation
( unilateral flexion and extension)
Segmental Compliance Test
• Assess the connective tissue compliance of
the arthrokinematic motions ( rocks and
slides) associated with various physiological
movements of the segment
• Clinician is attempting to appreciate the
quality of the “ give” present in the CT when
the segment is at R2
NDI Measurement Properties
Coefficients
• Internal consistency a=.87
• Test-retest reliability (several days) .89 to .94
• Correlates with SF-36 Physical Component
Score r=.53; Pain intensity r=.56; Patient
Specific Functional Scale (PSFS) score r=.80
NDI Measurement Properties
Scale Points
• Variation in a single score value ±3 (90% CI)
• Minimal detectable change 5 points
• Minimal clinically important difference 5 points
Neck Disability Index (NDI)
(Vernon & Mior 1991)
10
item self-report functional status measure
Items
Total
score value 0 (high function) to 50 (low)
About
20
scored on a 6 point scale (0 to 5)
3 to 5 minutes for patient to complete
seconds to score without computational aids
Objective Assessment
Segmental Integrity Tests
• Evaluate the ability of motion segment’s
passive elements to resist uni-planar
forces
• Test passive subsystem ( ligaments of
knee)
NZ / EZ Relationship
EZ
NZ
Boundary between R 1 and
R2
Stability Tests
Treatment
• Mobilization – traction, IMP
• Exercise
• Education
Traction
neutral and restriction
Strategies for Stabilization
Instability
• Loss of the ability of the spine to maintain
relationships between vertebrae in such a
way to prevent:
» spinal cord or nerve root damage
» incapacitating deformity
» severe pain
(Panjabi, 1990)
• Often defined as an increase in a particular
measure (eg: ADI>3mm)
Neutral Zone
(Panjabi, 1989)
• That part of the ROM
which requires very little
force to produce
minimal resistance to
the movement
Psycho
Social
Stability
Control
system
Passive
system
Active
system
Panjabi 1992
Efficient Movement = Optimal
Stabilization
Requirements
Intact bones, joints,
ligaments
Efficient and coordinated
muscle action
Appropriate neural
responses
Learning to control the
Deep and Postural
muscles
Edgepac Queensland Aust ‘99
Scapular muscle
control
Balanced force
couple around the
scapula
Poor postural position of the
scapula
Muscle impairments of the
axioscapular muscles
• Loss of holding capacity in any of the
upper, mid, + lower portions of trapezius
• Loss of holding capacity of serratus
anterior
Imbalance of large
posterior muscles
and deep anterior
muscles
Muscles impairments in
cervical pain syndromes
• Poor activation and holding capacity of
deep neck flexors
• Overactivity of the superficial muscles
that span cervical spine
Deep
stabilizing
SCM
SCM
muscles of the
neck
Muscle impairments of the
axioscapular muscles
• Overactivity of levator scapulae,
pectoralis major or minor , scalenes
• Overactivity of upper traps in response
to sensitive neural tissues
Stabilizing
Muscles of the
Scapula
Cervical Pain syndromes
• Superficial muscles attempt to stabilize
the neck but anatomically not designed
for segmental support
• Decreased capacity for co contraction of
deep neck flexors and extensors to
increase segmental stiffness
Cervical Pain Syndromes
• Poor pattern of superficial and deep
neck flexor synergy in sagittal plane
movements
• Often poor postural position of neck
and girdles
• Tightness suboccipital extensors
Suboccipitals become tight
Stretching often contraindicated
Neural tissue must be respected
Head and neck in mid
range neutral position,
face parallel to the
ceiling. May add towels
Avoid craniovertebral
extension
Stabilizer is placed behind the
neck suboccipitally
Stabilizer is inflated to fill
the suboccipital space
(approx 20mmHG)
Longus colli activation
Motor Control is NOT a
birthright
Treatment Advice
• No phasic ,erratic movement
• Emphasis on precision and control
• Discourage activity of superficial neck
flexors
Treatment Advice
• Train joint position sense
• Perform exercises at least twice a day
• Exercise must be pain free
• Deep muscle function does not return
automatically
Components of an Effective
Exercise Program
• Cardiovascular Endurance
• Muscle strength, endurance and coordination
• Flexibility
• Body Composition
Motor Learning
• Formal motor skill training
• Perception of the specific contraction
• Understand the task, what it feels like,
instructions, visual cues, different
postures/positions, various facilitation and
feedback
• Enhance the patients perception of the deep
muscle motor skill
• Focus on one particular muscle at a time
Motor Learning
Associative Stage  Automatic
Stage
• “Got the idea”  practice 
thousands of repetitions
• Care with fatigue
Motor Learning
Exercise Progression
• Commence co-activation of TA/multifidus
•
Combine with short neck flexors
•
Increase holding time
•
Increase number of contractions
•
Reduce feedback
• Add diaphragmatic breathing (abdominal wall
movement while maintaining a deep muscle
contraction) Intermediate steps to encourage air
flow: counting, talking