Cervical Spine STM

Cervical Spine Soft Tissue Mobilization Techniques

Trigger Points (TrP)

  • Definition: Trigger Points, commonly referred to as TrPs, are hyperirritable spots in skeletal muscle that are associated with a hypersensitive palpable nodules in taut bands of muscle fibers.

Referral Patterns

  • Sternocleidomastoid (SCM): Understanding referred pain patterns associated with TrPs in SCM,

  • Occur in Infraspinatus and Traps as well

TrP Examination and Release Techniques (Lab)

  • Techniques involve examining and releasing TrPs in the Upper Trap (UT) and SCM using a method called pincer palpation.

  • Infraspinatus: Use flat cross-fiber palpation; note the changes in muscle fiber alignment angles during palpation.

Suboccipital Release (Lab)

  • Technique:

    • Use digits of the hands (DIPs) to hook under the occiput.

    • Apply pressure to suboccipital muscles while keeping the head and cervical spine neutral.

Cervical Muscle Stretches (Lab)

  • General Guidelines:

    • For all stretches (except scalene): depress scapula on the treatment side prior to stretching.

    • Upper Trap:

    • Movement: Flexion, contralateral side bending (SB), ipsilateral rotation (ear to armpit).

    • Levator Scapulae:

    • Movement: Flexion, contralateral side bending, contralateral rotation (nose to armpit).

    • Scalene:

    • Movement: Extension of lower cervical spine (C/S), contralateral side bending.

    • Middle Scalene:

    • Movement: Contralateral side bending.

    • Anterior Scalene:

    • Movement: Contralateral side bending + slight ipsilateral rotation (ear toward armpit).

    • Posterior Scalene:

    • Movement: Contralateral side bending + slight contralateral rotation (nose toward armpit).

    • Note: For all stretches, ribs 1 and 2 can be depressed for additional stretching effect.

    • Perform all stretches in sitting position using passive range of motion (PROM) and overpressure techniques.

Review of Other Soft Tissue Techniques

  • General Massage Techniques (all require lubricant):

    • Effleurage: General stroking along muscle fibers.

    • Petrissage: Techniques include kneading, ringing, rolling, lifting, and milking of tissue.

    • Tapotement: Rhythmic percussion applied to the tissue.

Soft Tissue Techniques Explained

  • Transverse Friction Massage (TFM)/Cross Friction Massage (CFM):

    • Direction: Perpendicular to muscle fibers including muscles, tendons, and ligaments.

    • Technique: Begin lightly and gradually increase pressure; lubricant may be necessary.

  • Myofascial Release (MFR):

    • Technique: Gentle, sustained pressure applied to fascia focusing on TrP release, based on tissue feedback and individual responses. Possible mild muscle soreness after treatment due to posture/alignment changes.

    • Use of lubricant may be considered.

  • Neuromuscular Therapy Technique (NMT):

    • Involves pressure or friction using fingers, knuckles, or elbows.

    • It serves both diagnostic and therapeutic purposes, with great variability in pressure application. Targets fascia and muscle, indirectly aiding TrP relief and correcting pain and movement dysfunction.

  • MFR Techniques:

    • J Stroke: For skin and fascia mobility; holds tissue with one hand while stroking in a J pattern with the other.

    • Vertical Stroke: Parallel to fibers, enhancing mobility.

    • Transverse Stroke: Perpendicular to fibers enhances mobility across structures.

    • Cross-Hand Technique: Deep release technique that stretches fascia in opposing directions using both hands, held for 90-120 seconds.

Mobilizations with Movement (MWMs) for the Cervical Spine

  • General Tips for MWMs:

    • Ask the patient to move in the direction that is restricted and/or painful, with the aim to reduce or eliminate pain while increasing range of motion (ROM).

    • Should be a non-painful experience; if pain persists, adjust the approach by trying opposite motion or modifying hand placements or angles.

    • Perform spinal MWMs in full weight bearing for maximal functional effect, ensuring to follow joint facet planes.

    • Incorporate patient- or therapist-assisted overpressure at the end range for effectiveness.

    • In first treatment session, recommend 3 repetitions; subsequent sessions can increase to 10 repetitions either in physical therapy setting or as part of home exercise program (HEP).

Restricted Cervical Spinal Movements

  • Restricted Rotation (Unilateral PA MWM):

    • Example: If left rotation is restricted,

    • Technique: PT places thumb on right facet of the targeted vertebra; patient rotates left while PT performs a unilateral posterior-anterior (U PA) mobilization on the right facet and moves with the patient into left rotation.

  • Rotation Blocking MWM:

    • Example: If right rotation is restricted,

    • Technique: PT places thumbs on the right facet of the vertebra just below the site of restriction; patient rotates to the right while PT provides an additional right PA pressure to block the vertebra from rotating.

  • Restricted Flexion (Central or Bilateral PA MWM):

    • Example: If flexion is restricted,

    • Technique: PT places thumbs on the inferior aspect of the spinous process or on the right and left facets for patient comfort; patient moves into flexion guided by the PT applying PA mobilization and superior glide to encourage bilateral facet opening or gapping.

  • Restricted Extension (Central or Bilateral PA Blocking MWM):

    • Example: If extension is restricted,

    • Technique: PT places thumbs on the spinous process or facets of the vertebra below the target; patient moves into extension as PT provides PA mobilization towards the patient’s eyes to encourage bilateral facet closure or downglide of the vertebra directly above.

Self-MWM Techniques

  • Example*: Restricted right rotation (upper C/S):

    • Technique: Use edge of a belt or towel anchored on target vertebra (e.g., left C2); pull down with the contralateral hand while pulling the belt with the ipsilateral hand, ensuring a PA/upglide force is applied on the target level (L C2).

  • Example*: Restricted extension:

    • Technique: Place edge of a belt or towel on the affected vertebra or one level below; pull forward on the belt with both hands at an angle toward the patient’s eyes, while the patient drops their head back slowly, maintaining the forward pull on the belt.