Cervical spine

Sites of neurovascular compression

Scalenes, first rib, coracoid process

Spinal manipulation therapy (SMT)

Evidence currently suggests use for treating cervical radiculopathy pts in addition to TherEx

Sx of poor posture

Forward head, forwards shoulders, thoracic kyphosis

Thoracic SMT indications

Acute or mechanical neck pain, pts with cervical radiculopathy

Cervical myelopathy sx

Sensory loss in hands, wasting of hand intrinsic muscles, unsteady gait, Hoffman’s reflex, hyperreflexia, B+B dysfunction

Neoplastic condition sx

Pt over 50, PMH of CA, unexplained weight loss, constant pain without relief, night pain

Upper cervical instability sx

Occipital HAs, numbness, severe limit in neck AROM in all directions, signs of cervical myelopathy

Vertebral artery insufficiency sx

Drop attacks, dizziness related to neck movement, dysphasia, dysarthria, diplopia, positive cranial nerve signs

Systemic disease sx

High temperature, BP above 160/95 mmHg, resting pulse > 100bpm, resting respiration > 25bpm, generalized fatigue

Yellow flags

Catastrophic thinking, mood disorders, external locus of control, reliance on passive therapies, fear avoidance behavior, secondary gain

Prognostic factors for developing chronic neck pain

Pt over 40, LBP, hx of neck pain, cyclist, loss of grip strength, poor attitude, poor quality of life

Neck pain with mobility deficits

Sx: limited ROM with asymmetrical loss of motion, pain at end range, acute neck pain, may have hypomobile or painful thoracic and cervical segments. May have sx radiating into UE

Tx: cervical and thoracic mobs/manips, stretching/strengthening, ROM exercises, improved neuromuscular control

Neck pain with headaches

May be caused by trapped suboccipital nerve, upper c-spine dysfunction, suboccipital muscle spasm, and/or tension headaches

Sx: unilateral HAs, HA reproduced with cervical ROM and certain positions or palpitation, reduced ROM, reduced cervical segment mobility, + cranial cervical flexion test

Tx: increase ROM, cervical mobs/manips, posture correction, general strengthen/stretch. Focus on stretching suboccipitals. Suboccipital release, chin tucks, ‘yes’ nods, strengthen deep neck flexors, SNAG

Neck pain with coordination deficits

Often due to whiplash, MVA, or other trauma event. May have UE sx. Expected to recover in 2-3 months

Sx: chronic neck pain, strength and endurance deficits, + cranial cervical flexion test, + deep neck flexor test, may have TPs, proprioceptive deficits. Concussion-like sx including HA and nausea, trouble concentrating, hypersensitivity to stimuli. Mid-range pain that worsens at end range

Tx: pt ed and counseling, gradual increase in activity, TENS. Stretch/strengthen pecs, LS, UT, scalenes. Minimize immobilization/collar use

Neck pain with radiating pain

Sx: referred UE sx or radicular pain reproduced by tests. Sx along dermatomes/myotomes. + ULTT, + Spurling’s, + Distraction test, ipsilateral rotation ROM loss

Tx: traction in combination with TherEx, nerve mobs, centralize sx, mobs/manips. Don’t forget to treat related myotome deficits!

Cervical radiculopathy

Most common at C6-C7 nerve root. May be due to herniated nucleus pulposus, spondylosis, facet effusion, DJD, or facet dysfunction

Sx: + Spurling’s, +ULTT for median n., + distraction test, less than 60 degrees rotation to ipsilateral side

Tx: Can be approached similar to McKenzie derangement category. Pt ed to remain active, foraminal opening, arm support when walking/standing, neck retraction, centralize sx, traction, mobs/manips (thoracic SMT), nerve glides

Facet syndrome

Similar to ‘neck pain with mobility deficits’

Sx: unilateral and localized spine pain. Asymmetrical loss of motion

Tx: improve ROM, reduce pain, modalities PRN, AROM exercises, stretching, mobs/manips

Thoracic outlet syndrome (TOS)

Sx: compression of neurovasculature along brachial plexus and subclavian vessels distal to nerve roots. Commonly occurs at scalenes and first rib. Often aggravated by poor posture

Tx: stretch anterior shoulder, scalenes, UT/LS, scapular muscles. Improve posture, nerve glides, 1st rib mobs, improve breathing mechanics, pt ed on sustained positions

Pt may need surgical intervention

Spinal stenosis

Sx: narrowing of spinal canal leading to neurovascular compression

Tx: promote flexion exercises, open foramina, improve posture to reduce forward head, traction, neural mobs, avoid extension

Spondylosis with myelopathy

Sx: bony encroachment on spinal cord leading to UE/LE sx and weakness, headache, increased sx with extension

Tx: flexion exercises, open foramina, reduce forward head, traction, stabilization training, neural mobs