Lesson 7

Mid Cervical Spine

Assessment and Treatment

Arthrokinematics

Sidebend /rotation

U joints/ Z jts

ipsi inf, med, post

( IMP)

contra sup,ant, lat

( SAL)

Rotation / Side Bend

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

Mean Values and ranges of axial rotation of cervical motion segments CT scanning Penning , Wilmink 87

Normal ROM in axial rotation and coupled motion – biplanar radiography Mimura’89

Segment Axial rotation SD

Flex/ext

SD

Lateral flexion SD

C3-4 6 ( 5) -3( 5) 6( 7)

C4-5 4 (6) -2( 4) 6( 7)

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 =.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 scored on a 6 point scale (0 to 5)

Total score value 0 (high function) to 50 (low)

About 3 to 5 minutes for patient to complete

20 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

Boundary between R 1 and R2

NZ

EZ

Stability Tests

Treatment

• Mobilization – traction, IMP

• Exercise

• Education

Tractionneutral and restriction

Strategies for Stabilization

Instability• Loss of the ability of the spine to maintain

relationships between vertebrae in such away to prevent:

» spinal cord or nerve root damage» incapacitating deformity» severe pain (Panjabi, 1990)

• Often defined as an increase in a particularmeasure (eg: ADI>3mm)

Neutral Zone (Panjabi, 1989)

• That part of the ROM

which requires very little force to produce minimal resistance to the movement

Stability

Control

system

Passive

system

Active system

Panjabi 1992

Psycho Social

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

Poor postural position of the scapula

Balanced force couple around 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

muscles of the

neck

SCMSCM

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 co-ordination

• 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 LearningExercise 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