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Figure 13.
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Cervical Rotation Lateral Flexion Test
A
B
A, Cervical rotation. B, Lateral flexion.
during active ROM assessment. While this test assesses mobility
of the global cervicothoracic junction region, it may be used in
conjunction with first rib spring/mobility assessment to confirm
and more specifically target hypomobile structures.
In addition to using the CRLF test, clinicians can collect
information on impairments from a variety of mobility and
flexibility tests. In the authors’ experience, limitations in muscle
flexibility often accompany joint hypomobility and working
on one can influence the other. Joint mobilization or accessory
motion assessment, functional tasks, and range of motion
assessments can yield a collection of impairments that can then
serve as markers of progress when treating patients who have
neck pain with mobility deficits.
Assessing Neck Pain with Movement
Coordination Impairments, WAD
is group of patients has neck pain related to a traumatic
onset or whiplash (WAD). e WAD group or patients with
movement coordination impairments group is so named as one
primary finding in this group of patients is a constellation of
symptoms and signs which each relate to the motor control
system. Providers can identify patients for this subgroup
primarily through mechanism of onset, but also through a
collection of symptoms. ese include shoulder girdle pain or
referred upper extremity pain, dizziness, nausea, nonspecific
concussive symptoms, headache, and/or any of the following:
concentration difficulties, light sensitivity, heightened affective
distress, or general hypersensitivity to mechanical, odorous,
thermal, or acoustic stimuli. Obviously, many of these findings
could individually be considered traditional red flags for serious
conditions, and so an assumption is being made that patients
who are post-trauma or whiplash event have received careful
examination of the neurovascular and musculoskeletal structures
of the head and neck to rule out potentially life altering
complications that can result from injury to the neurovascular
structures in the cranio-cervical region.
e Quebec Task force classified WAD into 4 categories
85
:
WAD I is defined as neck complaints, with stiffness or tenderness
in the neck region and no physical signs of injury; WAD II is
defined as neck complaints, with stiffness or tenderness, and
some physical signs of injury, such as point tenderness or trouble
turning the head; WAD III is defined as neck complaints, with
stiffness or tenderness and neurological signs of injury, such as
changes to reflexes or weakness in the arms; and WAD IV is
defined as neck complaints, with an associated neck fracture or
dislocation. While this classification is useful, there still exists
heterogeneity of patient recovery trajectories even in the WAD
I category.
Providers can group patients with WAD by prognostic
trajectory as well. About 50% of people will recover from WAD
without persistent problems. But, the remaining 50% will
have persistent symptoms, with about 35% having moderate
persistent symptoms and 15% having severe persistent
symptoms. Poor recovery has been consistently reported to be
associated with moderate to high initial neck pain intensity and
neck-related disability, high posttraumatic stress symptoms, high
pain catastrophizing, low self-efficacy, and cold hyperalgesia
(Table 4).
85
Interestingly, the mechanism of the whiplash event
including direction and speed of impact seem to be only weak
prognostic factors.
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29
Whiplash and associated disorders present with
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33,86,87
recognizable characteristics.
Reduced muscle recruitment
in the cervical and shoulder girdle muscles are typically present.
Degenerative changes in posterior cervical muscles have been
reported. Sensorimotor dysfunction has been observed, with
head repositioning errors being increased in this patient
population. Reduced pain thresholds or widespread sensory
hypersensitivity may be present as well. Finally, patients with
WAD may present with psychosocial disturbances, including
depression, anxiety, and fear of movement.
81
e craniocervical flexion (CCF) test
assesses the
activation and endurance of the deep neck flexor muscle group.
For this assessment the patient is in a supine, hooklying position
with their head and neck in mid-range neutral. How this neutral
position is achieved depends on the patient’s thoracic posture.
Typically, a folded towel can be used under the occiput to
achieve this neutral cervical spine, but for patients with greater
thoracic kyphosis a larger towel may be needed. A biofeedback
cuff, or blood pressure cuff, is placed under the natural lordotic
curve of the neck and inflated to 20 mmHg with the patient at
rest. Once the cuff is inflated some pressures may need to be
applied randomly to evenly distribute the air throughout the
cuff to ensure accurate measurements.
e patient is then cued to gently nod their head for 5 bouts
with 10 second holds and 10 second rests in between. Each
bout increases the target pressure the patient should hold by
increments of 2 mmHg: 22, 24, 26, 28, 30 mmHg x10 seconds
each. Common errors with this test are the patient lifting their
head up or pushing down into cervical retraction. While the
patient performs the head nod the therapist gently palpates to
monitor for unwarranted SCM, platysma, and infra- and suprahyoid muscles activation. To assist with this, the patient can
slightly separate their teeth and touch their tongue to the roof
of their mouth during the test.
e test is stopped when the patient is unable to achieve
the next pressure target without the above-mentioned
compensations, or if the pressure decreases by 20% over the 10
second hold. ere are 2 scores for this test: (1) the activation
score which is the maximum pressure achieved and held for 10
second, and (2) the performance index which is the maximum
pressure achieved and held for 10 seconds multiplied by the
number of repetitions that this maximum pressure is maintained
for 10 seconds (up to 10 repetitions).
82,83
e neck flexor muscle endurance test
measures the
time duration a patient is able to lift and hold the head and
neck off the table against gravity. e patient is supine and
cued to tuck their chin and cued to slightly lift their head.
e patient should maintain full CCF and only lift the head
approximately 2.5 cm (1 inch) off the table and the therapist
should be observing for a loss of CCF. is is most easily done
by observing the wrinkles that form near the jaw of the patient
and the therapist placing their fingers on the table below the
occiput. e test is ended when the flexion is lost with the
evident loss of the wrinkles at the jaw or when the patient’s
head touches the therapist’s fingers for longer than 1 second.
75
In a study by Harris et al,88 41 participants with and without
neck pain performed this test. Two raters tested all participants
at baseline, and those without neck pain were tested again 1
week later. Participants without neck pain performed the test
for a mean ± standard deviation of 38.95 ± 26.4 seconds, while
those with neck pain performed the test for a mean of 24.1 ±
12.8 seconds. e reliability of this test for individuals without
neck pain was good to high: intraclass correlation coefficient
(ICC)
= 0.82 to 0.91, standard error of measurement (SEM)
3,1
was 8.0 to 11.0 seconds. For those with neck pain, the reliability
was good: ICC
= 0.67 and the SEM was 11.5 seconds.
2,1
88
e same logic holds true with this assessment of
the anterior cervical flexors as this assessment can be positive
for many categories of patients. In fact, the authors of this
monograph contend that the reported “normal” duration of the
test (38.95 seconds) might be unreasonably long compared to
the collective performance of the deep neck flexors they see on
patients in their clinics. It should not be surprising for clinicians
if patients from all 4 categories of patients present with some
extent of deep neck flexor endurance impairments.
Another useful test with patients in this classification is
algometric assessment of pressure pain threshold (PPT).
69–71
In some patients, the recognition of painful and non-painful
stimuli can change in response to changes in central processing
of pain. is typically, though not always, happens when
symptoms have been persistent. Patients may present with
pain to non-painful stimuli (allodynia) or exaggerated pain
perception to painful stimuli (hyperalgesia). Additionally,
patients may lose the ability to localize pain stimuli and could
be described as having diffuse pain. A surrogate measure of
changes in central processing of pain is PPT. e following is
an example measurement procedure for local PPT in the upper
trapezius muscle and can reflect impaired pain processing in
patients.
With the patient seated, the therapist positions a digital
pressure algometer perpendicular to the upper fibers of the
trapezius muscle (approximately 5 to 8 cm superomedial to the
superior angle of the scapula), and/or the tibialis anterior muscle
belly. Pressure is gradually applied at a rate of approximately
4 to 5 N/s (40-50 kPa/s). e patient indicates when the
sensation switches from just pressure to pain with the push of a
button or verbally. e assessment is repeated for 3 repetitions
on each side, with at least 30-second between tests. e results
are averaged and documented as the pressure perceived when
achieving the pain threshold in N/cm
2
, psi, or kPa.
89
Reference values for PPT are established for patients
90
with acute and chronic neck pain.
Lower values indicate a
mechanical hypersensitivity to pain. When lower values are
evident only in the region of complaint, such as when there is
a lower PPT at the upper trapezius and not the tibialis anterior,
this can be interpreted as a local sensitivity. Additionally, when
30
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the PPT values are lower in both local and distal locations, this
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raises the possibility of a central nociceptive processing disorder.
Reliability of PPT testing is excellent for intrarater agreement.
Specific information about diagnostic validity is presented in
the Neck Pain CPG by Blanpied et al.
8
Assessing Neck Pain with Headache
Patients with neck pain who also complain of headaches
can form their own impairment-based category, provided
the headache is of cervical origin. While there are many
headache classifications, physical therapists typically manage
headaches related to craniocervical movement dysfunctions,
or cervicogenic headaches. Cervicogenic headaches present
the occiput anteriorly and laterally to the temporal region.
Cervicogenic headaches tend to present unilaterally and are
related to changes in movement of the craniocervical spine
and/or temporomandibular joint. When assessing for this pain,
careful questioning about headaches is important to both rule
out other types of headaches and more serious pathologies for
which headaches are a symptom.
Tension-type headaches, cluster headaches, and migraine
headaches are types of headaches that do not typically respond
well to physical therapy interventions. Individuals with
cervicogenic headaches are more likely to present with ROM
deficits and painful segmental mobility of the upper 3 cervical
91
segments than people with other headache types.
Weakness
or impaired coordination of the deep neck flexor muscles is
92
also a common finding.
Additionally, it is recommended that
that these findings tend not to be common with other types of
headaches.
Additionally, for this particular neck pain category, the
67,68
cervical flexion-rotation test
is used to assess upper cervical
joint mobility. Specifically, this is a measurement of passive
rotation ROM at the AA (C1-2) joint. To perform the test,
the patient is supine and positioned superiorly on the table so
the clinician can passively flex the cervical spine to end range
without having to lift and hold the head away from their body.
e neck is passively moved into full flexion to block rotation
motion from occurring in the lower cervical segments. To help
maintain the fully flexed position, the therapist can use their
abdomen as a barrier on the patient’s posterior cranium. e
clinician then passively rotates the head left and right ensuring
the cervical spine remains at very end-range flexion and does
not drift into cervical side flexion. e end of ROM in rotation
is determined either by patient report of onset of pain or firm
resistance felt by the clinician, whichever comes first. Generally,
if a ROM >45° is noted it is worth ensuring that end-range
neck flexion was not lost, and that neck side flexion did not
occur. e clinician quantifies the cervical rotation ROM either
by visual estimate with the nose as a guide, or the use of a
goniometer. A positive test has been defined as a restriction of
rotation ROM with a cut-off of less than 32° of rotation or a 10°
reduction in the visually estimated range to either side. Specific
information about diagnostic validity is presented in the Neck
Pain CPG by Blanpied et al.
8
Assessing Neck Pain with Radiating Pain
Classification of Headache Disorders (https://ichd-3.org/)
from the International Headache Society for more complete
information on the diagnosis and management of various
headaches.
When assessing patients with headaches, careful
investigation about the headaches is important. Frequency,
circumstances of onset, duration, and associated symptoms are
critical pieces of information. For example, sharp, stabbing,
sudden headaches that occur at night and are associated with
autonomic nervous system signs like watering eyes can be a
form of cluster headache. Headaches that involve the entire
head, present with an aura at onset and are debilitating, describe
a migraine type headache. Some headaches can be symptoms
of more serious conditions like brain cancers or vascular
pathology, and clinicians should be on the watch for associated
neurological signs. A Chiari malformation can present as neck
pain with headache and is caused by the herniation of the
cerebellar tonsils through the foramen magnum.
e diagnosis of cervicogenic headache can be assisted by
examining a pattern of common findings. Unilateral headaches
of an intermittent nature, weakness of the deep neck flexors,
and segmental hypomobility of the upper cervical spine, all
93,94
suggest cervicogenic headaches. Jull et al
reported in 2007
typically referred to as cervical radiculopathy, or neck pain with
associated arm pain and often neurological impairment. While
there is no gold standard to identify cervical radiculopathy
outside of nerve conduction and electromyography testing
protocols, there are several facets to patient presentations that
enable them to be easily classified into this category. First,
patients will have pain or symptoms such as numbness and
tingling that radiate into the distal upper extremity or possibly
the medial scapular border (Cloward sign). Also, patients may
present with a cluster of findings that make the diagnosis of
cervical radiculopathy more likely, including: limited ipsilateral
cervical rotation less than 60°, positive Upper Limb Tension
Test A (median nerve bias), positive Spurling test, and a positive
95
neck distraction test.
Wainner et al95 reported that positive
findings during the clinical exam for these 4 variables resulted
in a positive likelihood ratio of 30.3 for the presence of cervical
radiculopathy. Within this cluster, the Upper Limb Tension
Test A was the most sensitive item and could be used to ruleout cervical radiculopathy when negative.
95
For patients with suspected radiculopathy, a thorough
neurological screen should be performed that assesses segmental
myotomes and dermatomes. Discriminative touch and muscle
activation deficits should be noted according to the spinal
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31
segment they arise from. As an aside, when considering the
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neurologic screen, patients presenting with more significant
neurological findings can somewhat alleviate the need to
identify the items from the cluster of tests proposed by Wainner
95
because the presence of such deficits make the diagnosis
et al,
8,12,96
of cervical radiculopathy more obvious.
Table 9 reviews
key dermatome, myotome, and deep tendon reflex testing for
the cervical spine.
65,72–75
e Spurling test
is a provocation test where the
patient is seated and asked to laterally flex the head to the
painful side. e clinician provides a compression force of
approximately 7 kg (~15 lbs) through the top of the head. is
force theoretically narrows the intervertebral foramen (Figure
14). A positive test reproduces the patient’s upper extremity
symptoms. e test is not indicated if the patient is reporting
their symptoms are present because in that case provocation of
additional symptoms is not warranted.
72,76
e neck distraction test
is performed in supine and
seeks to confirm radiculopathy if the patient’s symptoms are
reduced or eliminated with axial distraction of the cervical spine
(Figure 15). e anatomical rationale for this is that the traction
increases the size of the lateral foramen and reduces pressure on
the nerve root. To perform the test, the clinician grasps under
Figure 14.
Spurling Test
Table 9.
Key Muscles and Dermatomal Areas for Neurological Testing1
Nerve
Root
C5
Deltoid: shoulder in 90° abduction, resistance against lateral upper arm
Key Muscles for Manual Testing Dermatomal Area
into adduction
C6
Biceps brachii: elbow at 90° flexion with forearm in supination, resistance
against distal forearm into elbow extension
Extensor carpi radialis longus/brevis: wrist extended and radially deviated
with forearm pronated, resistance against dorsum of hand into flexion
and ulnar deviation
C7
Triceps: shoulder and elbow flexed to 90° with forearm supinated,
resistance against dorsum of distal forearm into elbow flexion
Flexor carpi radialis: wrist flexed and radially deviated with forearm
supinated, resistance against thenar eminence into wrist extension and
ulnar deviation
C8 Abductor pollicis brevis: thumb placed in abduction, resistance against
proximal phalanx into adduction
T1 First dorsal interossei: index and middle finger are separated, resistance
against the medial aspect of proximal phalanx of the index finger toward
the middle finger
Key Muscles
for Reflexes
Lateral forearm Biceps brachii
(C5, C6)
Distal thumb Brachioradialis
(C5, C6)
Distal dorsal aspect
Triceps
of middle finger
(C7)
Distal 5th finger N/A
Medial forearm N/A
32
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Figure 15.
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Distraction Test
the chin and occiput, flexes the patient’s neck slightly into a
position of comfort, and gradually applies a distraction force of
up to approximately 14 kg. is test is not indicated (useful) if
the patient has no upper extremity or scapular region symptoms
at the time of the examination.
Because the most common area for cervical nerve root
involvement is C5-6, the most commonly impaired nerve
for neurodynamic testing should be the median nerve, which
76–79
is assessed by the Upper Limb Tension Test A.
is test
assesses the amount of mobility of the neural elements of the
upper limb while determining whether the patient’s upper
quarter symptoms are elicited during performance of the test.
Upper limb tension tests (also commonly referred to
as neurodynamic mobility testing) are performed with the
patient supine, legs uncrossed, and ideally without a pillow
under the head (Figure 16). During performance of the upper
limb tension test that places a bias toward testing the patient’s
response to tension placed on the median nerve, the therapist
uses a pistol grip to hold the patient’s hand, with the therapist’s
index finger maintaining the patient’s thumb into extension,
while the patient’s index and middle fingers (and 4th and
5th digits if possible) are also held into extension. en, the
examiner sequentially introduces the following movements to
the tested upper extremity:
1.
Preventing scapular elevation (formerly scapular depression)
Shoulder abduction to about 90° with the elbow flexed
2.
3. Forearm supination, followed by wrist and fingers extension
4. Shoulder lateral rotation to about 90°
5. Elbow extension
6. Contralateral then ipsilateral cervical side flexion
(contralateral side flexion is expected to increase symptoms
by sensitizing/tensioning the nerves, while ipsilateral side
Figure 16.
Upper Limb Neurodynamic Tension
Tests
A B
C
A, Test A: median nerve bias. B, Test B: radial nerve
bias. C, Test C: Ulnar nerve bias.
flexion should relieve symptoms reproduced in the earlier
part of the test)
97
A positive test occurs when any of the following findings
are present: reproduction of all or part of the patient’s
symptoms; side-to-side differences of greater than 10° of elbow
extension or wrist extension; or when testing the symptomatic
side, contralateral cervical side flexion increases the patient’s
symptoms, or ipsilateral cervical side flexion decreases the
patient’s symptoms.
To perform the Valsalva test
76,80
the patient bears down
without exhaling to increase intrathecal pressure and elicit upper
quarter symptoms. is is not a test commonly performed in
physical therapist practice but is included in the Blanpied et
8
al
clinical guidelines due to a sufficient amount of supporting
evidence. Clinicians should be careful not to overload the
cardiovascular system and this test might not be appropriate
for patients with hypertension. e test is performed in sitting
and the patient restricts exhalation for 2-3 seconds. A positive
response occurs with reproduction of radicular symptoms.
e upper limb tension tests B and C have a radial and
ulnar nerve neurodynamic mobility bias, respectively. While
these assessments are not typically part of the diagnosis of
cervical radiculopathy, they can inform the clinician about
neural mobility which can be the source of some radiating arm
pain without positive neurological findings. Nee et al
97
have
suggested that differences of 10% or more side-to-side in terms
of motion of sensitizing segments can be considered positive
for any of the neurodynamic mobility tests. Clinicians can note
the irritability of the patient to assist with choosing the proper
intensity of interventions.
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33
e Upper Limb Tension Test B assesses the amount
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of mobility of the neural elements (radial nerve bias) of the
upper limb while determining whether the patient’s upper
quarter symptoms are elicited during performance of the test.
e test is performed with the patient supine, legs uncrossed,
and ideally without a pillow under the head. For this test, the
patient should be angled so their shoulder is slightly off the
table towards the therapist and their feet shifted to the opposite
side of the plinth. e therapist can then use their thigh to
prevent scapular elevation and use both hands to support and
control the patient’s arm. e hand position for this test has
the patient making a soft fist while holding their thumb, and
the therapist grasps this fist to control the wrist and forearm
motions described below. During performance of the upper
limb tension test that places a bias toward testing the patient’s
response to tension placed on the radial nerve, the examiner
sequentially introduces the following movements to the tested
upper extremity:
1.
Preventing scapular elevation (formerly scapular depression)
2. Elbow extension
3. Medial rotation of the whole arm
4. Forearm pronation
Wrist, finger, and thumb flexion
5.
6.
Contralateral then ipsilateral cervical spine side flexion
(contralateral side flexion is expected to increase symptoms
by sensitizing/tensioning the nerves, while ipsilateral side
flexion should relieve symptoms reproduced in the earlier
part of the test)
e Upper Limb Tension Test C assesses the amount of
mobility of the neural elements (ulnar nerve bias) of the upper
limb while determining whether the patient’s upper quarter
symptoms are elicited during performance of the test. e test
is performed with the patient supine, legs uncrossed, and ideally
without a pillow behind the head. When holding the patient’s
hand correctly, the therapist is palm to palm with the therapist
maintaining the patient’s fingers into extension. For different
hand sizes, the priority is maintaining the 3rd-5th digits into
extension because those are innervated by the ulnar nerve.
During performance of the upper limb tension test that places
a bias toward testing the patient’s response to tension placed
on the ulnar nerve, the examiner sequentially introduces the
following movements to the tested upper extremity:
1. Preventing scapular elevation (formerly scapular depression)
2. Shoulder abduction to about 90°
3. Shoulder external rotation to about 90°
4. Forearm pronation
5. Wrist and fingers extension
6. Elbow flexion
7. Contralateral then ipsilateral cervical side flexion
(contralateral side flexion is expected to increase symptoms
by sensitizing/tensioning the nerves, while ipsilateral side
flexion should relieve symptoms reproduced in the earlier
part of the test)
Summary of Key Examination Findings
When evaluating a patient with neck pain over an episode
of care, clinicians should include assessments of impairments
of body function that can establish baselines, monitor changes
over time, and be helpful in clinical decision making to rule
in or rule out: (1) neck pain with mobility deficits, including
cervical active ROM, the CRLF test, and cervical and thoracic
segmental mobility tests; (2) neck pain with movement
coordination impairments, including the CCF and neck flexor
muscle endurance tests; (3) neck pain with headache, including
cervical active ROM, the cervical flexion-rotation test, and
upper cervical segmental mobility testing; and (4) neck pain
with radiating pain, including neurodynamic testing, Spurling
test, the distraction test, and the Valsalva test. Clinicians should
include algometric assessment of PPT for classifying pain. If
PPT tools are unavailable, quantitative sensory testing, using a
range of stimuli and tested at various locations in the body can
be a very useful clinical alternative as a way to quantify changes
in sensory processing.
98
Stage of Healing Considerations
Acute, subacute, and chronic stages are often described
as time-based stages helpful in classifying patient conditions.
But time-based stages are only moderately helpful in making
treatment decisions. Alternatively, staging can be based on
irritability level. Typically, a high-level of irritability is present
in the acute phase of the condition. Conversely, chronic
conditions often have a low level of irritability. However,
chronic presentations that include central nociplastic changes
can present as quite irritable. Where the alignment of irritability
and the duration of symptoms does not match accordingly,
clinicians need to make judgments about tissue healing,
prognosis, and treatment tolerance on a patient-by-patient
8,96
basis.
Summary
In summary, clinicians should use motion limitations in
the cervical and upper thoracic regions, presence of cervicogenic
headache, history of trauma, and referred or radiating pain into
an upper extremity as useful clinical findings for classifying a
8,10,96
patient with neck pain into the following categories
:
• Neck pain with mobility deficits
• Neck pain with movement coordination impairments
(including WAD)
• Neck pain with headaches (cervicogenic headache)
• Neck pain with radiating pain (radicular)
It is important to note that these categories will not
be exclusive or exhaustive. erefore, the assignment of an
individual patient into the category that “best fits” the patient’s
current clinical picture relies on clinical reasoning and judgment
of the clinician. e next section, evidence for interventions,
will utilize this model of classification for patient management.
34
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CONDITIONS-SPECIFIC EVIDENCE-BASED
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REHABILITATION CONCEPTS
An efficient approach to intervention strategies for patients
with neck pain is to model off of the 4 neck pain classifications
previously discussed. Furthering this model, a table that guides
interventions was also produced by Blanpied et al,
serve as our guide to discuss interventions (Figure 17).
8
and will
It should be noted that there is a significant difference
between interventions specifically supported by evidence and
interventions that are clinically indicated. Meaning that while
an intervention like a cervical sustained natural apophyseal
glide (SNAG) is listed under neck pain with headache, this
intervention can also be performed for any patients with
mobility deficits of the cervical spine.
8,99–101
us, the guidance
Figure 17.
Intervention Strategies Based on Neck Pain Classification from the Academy of Orthopaedic Physical erapy
Clinical Practice Guidelines
83
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35
in the table outlines which interventions have the most
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evidence for each classification, but should not be taken to use
as justification for exclusion of any interventions that are within
the scope of physical therapist practice. In this way, clinical
guidelines can help with decision making while not assuming
any unintended tyrannical role in clinical practice.
Interventions Strategies:
Neck Pain with Mobility Decits
e interventions for neck pain with mobility deficit
align themselves on a continuum. At one end is mobility
interventions to improve painful motions; the other end is
coordination, strengthening, and endurance exercises to help
maintain the mobility and functional gains that the patient
has made. e typical starting point for most patients in this
classification will likely be mobility interventions such as
cervical and thoracic mobilization/manipulation.
8,96,102–105
Commonly, joint mobilization (central PA and/or unilateral PA
pressure) is used to address spinal segmental mobility deficits.
e procedure to perform these techniques as an intervention
is essentially the same as when assessing for segmental accessory
mobility. However, a difference lies in the duration and
amplitude of oscillation that results in a therapeutic change,
determined by noting a difference in joint mobility and/or pain
with reassessment following the intervention.
One important point to discuss is the utility of
thoracic manipulation for patients with neck pain. oracic
manipulation has supporting evidence for use in the acute,
subacute, and chronic stages of neck pain with mobility deficits.
It may seem counterintuitive to direct an intervention away
from the cervical spine, however, it seems this is a particularly
strong case of regional effects from treatment. is could be due
to mechanical linkages of muscles and structures that cross from
the thoracic to the cervical spine, or due to pain processing and
26
neurophysiological effects of spinal manipulation.
Interestingly, unlike cervical mobilizations where an
equivalency is seen in the evidence for both mobilization and
manipulation, thoracic joint mobilization does not have the
same preponderance of evidence supporting its use than what
we see for thoracic manipulation (defined as high-velocity
low-amplitude [HVLA] technique). is could be due to
lack of research specifically on thoracic mobilizations or due
to some other reason in which interventions in the thoracic
spine influence symptom experiences differently. From the
authors’ perspective, manipulation of the thoracic spine for
patients with neck pain is a safe, efficient, and effective strategy
for intervention and the use of mobilizations is reserved
for a minority of patients where manipulation might not be
indicated. For all stages of healing, patients who have neck
pain with mobility deficits can benefit from a strategy to both
restore mobility, and subsequently, optimize muscle strength,
endurance, and aerobic fitness. Below are key interventions for
patients with neck pain and mobility deficits.
Central and unilateral PA mobilizations
e assessment for central and unilateral PA segmental
mobility can also be used as an intervention (Figure 7A-B).
e decision to continue with using the central or unilateral
PA mobilization as an intervention depends on patient comfort
in the prone position, therapist preference, and symptom
presentation. If the assessment reproduces the patient’s
symptoms in a manner that resolves immediately once the PA
stops, or that eases the symptoms, then this could be a potential
intervention. It is important to regularly communicate with
the patient about their symptom status because the therapist is
unable to view the patient’s facial expressions for potential signs
of discomfort.
e patient and therapist positions remain the same as
for the PA assessment. e intervention mobilizations are
performed at roughly 2 Hz/sec (this is roughly the beat of
the song “Row Row Row Your Boat”), at a grade dependent
on the treatment objective and the patient’s tolerance during
assessment. Table 10 outlines grades of mobilizations that are
not specific to the cervical spine. Mobilizations are generally
performed in 2-3 bouts of 30 seconds depending on patient
response. Following the intervention, the therapist should
reassess the patient’s objective finding(s) that reproduced their
symptoms for qualitative and quantitative changes.
Cervical lateral glide
is intervention can be performed as a mobilization or
manipulation. Same as the lateral glide assessment, the patient is
supine and the physical therapist will locate the spinous process
of the desired segment to treat. For the assessment, the therapist
placed their index and middle fingers of each hand contacting
the articular pillar on both sides of a segment’s spinous
process. e therapist then systematically works up or down
the spine assessing both the quality of motion as hypermobile,
hypomobile, or normal, as well as symptom modification.
As a decision-making starting point, the location of the
patient’s pain during the cervical ROM assessment can suggest
a facet opening or closing issue. For example, if the patient
rotates to the right, pain on the right side of the neck could
suggest a facet closing issue on the right, and pain on the left
side of the neck could suggest a left facet opening issue. A left
lateral glide, with the right hand mobilizing a segment towards
the left, will generally close the right facets and open the left
facets. For patients with lower irritability, the therapist may
choose to work into the direction of suspected mobility deficits,
while patients with moderate to higher irritability may benefit
from working away from the initial direction of suspected issue.
Patient response during the intervention as well as the results
of retesting after the intervention will ultimately dictate the
direction of mobilization that will benefit the patient most.
For the intervention, the therapist contacts the desired
articular pillar with the first (index finger) metacarpophalangeal
36
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Table 10.
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Grades of Mobilization Based on Maitland
134
Grade Description
Grade I Low amplitude mobilization at the beginning of range before any
Primary
Treatment Goal
Pain modulation Moderate to high
resistance is noted
Grade II Larger amplitude mobilization from the beginning of the range before
Pain modulation Moderate to high
any resistance is noted
Grade III Larger amplitude mobilization in mid-range and working into
Increase ROM Low
resistance and towards the end resistance
Grade IV Small amplitude mobilization at the end-range of resistance Increase ROM Low
Abbreviation: ROM, range of motion
(MCP) joint and supports the contralateral occipital region with
their stabilizing hand posterior to the patient’s ear. e therapist
then moves their body to the intervention side of the plinth so
Figure 18.
Cervical (Upglide) Manipulation
their forearm points in the direction of the mobilization with
a neutral wrist. e therapist performs a mobilization grade
(I-IV) consistent with the patient’s irritability and treatment
A
goal (Figure 8). Mobilizations are generally performed in 2-3
bouts of 30 seconds depending on patient response. For a
manipulation, the therapist will mobilize to the end-range of
resistance, then provide a HVLA force in a lateral direction.
Following the intervention, the therapist should reassess the
patient’s objective finding(s) that reproduced their symptoms
for qualitative and quantitative changes.
Symptom
Irritability
Cervical upglide
is is a technique that is thought of as a facet opening
technique and can be performed as a mobilization or
manipulation. Same as mentioned in the previous technique,
the patient’s tolerance to the position will dictate the direction
of mobilization or manipulation more than the biomechanical
rationale of facet opening or closing. Because this technique’s
primary motion is rotatory, this can be helpful for individuals
with rotation limitation though not exclusively.
For cervical upglides, the patient is supine with head and
neck neutral (Figure 18A). e mobilizing hand will contact
the articular pillar of the desired segment with the first (index)
MCP joint (or distal phalanx) and the zygomatic arch with
the thumb. is requires the therapist to internally rotate
the shoulder, moving the elbow away from the patient. e
stabilizing hand cradles the posterolateral occiput (around the
ear). e first motion is contralateral rotation until resistance
is felt in the mobilizing hand at the targeted segment, then,
ipsilateral side flexion at the vertebral level is created by the
therapist shifting their body towards the corner of the plinth.
Note that this is a small movement, similar to a small lateral
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B
A, Cradle hold. B, Chin hold.
glide, and the head stays centered on the trunk. From this
position a graded mobilization or HVLA (quick but small
movement) force is directed towards the opposite eye. is
movement is generated 50/50 with pronation of the mobilizing
hand and supination of the stabilizing hand.
37
Alternative chin hold: For this set-up, the table height must
Figure 19. Cervical (Downglide) Manipulation
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be higher. en, instead of the therapist contacting the occiput
with the stabilizing hand, the forearm is wrapped posterior to
the patient’s ear with a gentle hold on the chin (Figure 18B).
As with all other techniques, following the intervention,
the therapist should reassess the patient’s objective finding(s)
that reproduced their symptoms for qualitative and quantitative
changes.
Cervical downglide
is is a technique that is thought of as a facet closing
technique and can be performed as a mobilization or
manipulation. Same as mentioned in the previous technique,
the patient’s tolerance to the position will dictate the direction
of mobilization or manipulation more than the biomechanical
rationale of facet opening or closing. Because this technique’s
primary motion is translation, this can be helpful for individuals
with limited side flexion though not exclusively.
For this technique, the patient is supine with the head
and neck in neutral (Figure 19). e mobilizing hand
contacts the articular pillar of the desired segment with the
first MCP joint using a lumbrical grip. e stabilizing hand
cradles the posterolateral occiput (around the ear). e first
motion is ipsilateral side flexion at the vertebral level created
by the therapist shifting their body towards the corner of the
plinth, then, contralateral rotation until resistance is felt in the
mobilizing hand at the segment is performed. From this position
a mobilization or HVLA directed towards the contralateral hip
is performed.
T1 vertebra and thus can be affected by dysfunction in the
cervicothoracic junction.
To perform this intervention, the patient is seated and
moved backward until they are sitting near the back edge of the
plinth (Figure 20). e therapist is standing in a stride stance
behind the patient. For the set up the patient horizontally
abducts their arms while the therapist wraps their arms around
the patient’s shoulder/axillary region interlocking fingers behind
the patient’s neck and cues the patient to then interlock their
fingers together over the therapist’s hands. Clinicians should
be careful not to provide pressure on the posterior neck and
press the patient into cervical flexion. Once in this position,
the therapist shifts their weight back slightly (50/50 on each
leg), adducts their arms applying compression into the patient’s
ribcage, and retracts their scapulae to apply set-up resistance.
For the manipulation, the therapist applies a HVLA force
Figure 20.
A
Seated Cervicothoracic Manipulation
Cervicothoracic junction manipulation (seated)
e seated cervicothoracic junction manipulation is a
possible intervention for an individual with neck pain with
mobility deficits for whom the therapist has noted hypomobility
in the lower cervical and/or upper thoracic regions. e patient
may report lower cervical pain with sitting or when performing
an active or passive cervical retraction, and may possibly
have a positive CRLF test, because the 1st rib attaches to the
Figure 19.
Cervical (Downglide) Manipulation
B
A, Lateral view. B, Anterior view.
38
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