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The Cervical Spine

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Anatomy

Cervical spine is composed of two functional units.

1. Craniovertebral (CV)
 Atlanto-occipital (AO)
 Atlantoaxial (AA) joints

2. Mid-lower cervical spine

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Atlanto-Occipital Joint

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Atlanto-Occipital Joint Movement
Flexion/Extension/Left Side Flex with
Right Rotation

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Atlantoaxial Joint

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Atlantoaxial Joint Movement
Flexion/Extension/Left Rotation with
Right Side Flexion

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Ligaments of CV Complex

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Midcervical Spine
C2-T1
Composed of several joints

Zygapophyseal (paired)
Uncovertebral (paired)
Interbody (disk)

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Uncovertebral/Interbody Joint

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Motion at Midcervical Spine

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ROM of Intervertebral Segments
Normal/Hypermobile – Elastic/Neutral Zone

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Motion at Midcervical Spine
Consists of

Flexion
Extension
Rotation/side flexion coupling
ipsilaterally

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Vascular and Nervous System

Vertebral artery tests should be performed for


each patient before performing end range
rotation of the neck, and particularly with the
addition of extension and traction.
The C1 nerve root exits through the
osseoligamentous tunnel formed by the
posterior AO membrane, which puts it at risk for
impingement.

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Craniovertebral Musculature

Muscle Action
 Rectus capitis posterior  AO extension
minor  CV extension and
 Rectus capitis posterior ipsilateral rotation
major  AO ipsilateral
 Superior oblique SF/extenstion
 Inferior oblique  AO ipsilateral rotation
 Rectus capitis lateralis  AO ipsilateral SF
 Rectus capitis anterior  AO flexion

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Muscles
Midcervical – Flexion

Longus colli
Longus capitis
Anterior scalenes
Sternocleidomastiod

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Midcervical Extension

 SCM  Semispinalis, capitis, and


 Trapezius (upper fibers) cervicis
 Levator scapula  Longissimus, capitis, and
 Splenius capitis and cervicis
cervicis  Iliocostalis cervicis
 Spinalis, capitis and  Interspinalis (most distinct
cervicis (blends with in CSP)
semispinalis)  Multifidus
 Rotatores (inconsistent)

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Examination and Evaluation
Examination should include entire spine,
particularly the thoracic spine, the TMJ, and
the shoulder girdle complex.

History and Clearing Tests

Functional questionnaires (neck disability


index, etc.)
Shoulder girdle tests (if indicated)

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Posture Examination

Static Alignment
Standing vs. sitting alignment – All
3 planes
Supine alignment
Assess resting position of each
vertebral segment through
palpation

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Movement Examination
Movement/Motion tests
 AROM  Myofascial extensibility
 Combined movements  Muscle lengths
 Cervical spine passive  Neuromeningeal
mobility extensibility
 Passive intervertebral  Upper limb tension tests
movements (median, radial, ulnar
 Passive accessory nerve bias)
vertebral movements

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Muscle Performance, Neurologic, and
Special Tests

Manual muscle tests


(recruitment, strength,
endurance)
Neurologic exam of sensation,
motor activity, and reflex integrity
Stability tests
Vertebral artery tests
Foraminal compression test

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Therapeutic Exercise Interventions for
Common Physiologic Impairments
Impaired Muscle Performance

Deep anterior cervical flexors tend to weaken.

Patient is taught to perform a preset nod to


activate deep stabilizing muscles (cervical
core) prior to any motion of the head.

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Therapeutic Exercise Intervention
Deep Cervical Flexors
Primary exercise is
head nod exercise.
Discourage use of
SCMs.
Consider gravity-
lessened position
initially.

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Graduate from Deep Cervical Flexors
to SCM/Scalene-Assisted

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Cervical Extensors

NME can be effective in initial stages of training.


Teach patient to apply resistance to the
contraction of specific muscle determined to be
weak.

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Cervical Extensors – Exercise Example

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Specific Manual Resistance to
Cervical Extensors

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Rotation and Side Flexion Components

 Foam wedge can be used for autoresistance.


 Sidelying with towel/roll used as a fulcrum.

Strengthening Functional Movement Patterns


 Once patient is able to perform movements without
hypertranslation, graduate to multiplanar movements.

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Side Flexor and Rotator Activation

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Mobility Impairment

Hypomobility
Segmental articular mobility restriction
Capsular thickening and contracture
Degenerative bony changes
Segmental muscle spasm
Myofascial extensibility
Adverse neuromeningeal tension

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Therapeutic Exercise Considerations

Postural education – correct FHP


ROM exercises in restricted planes
(consider gravity!)
Exercise localized segment according to
mobility test
Stretch short muscles
Strengthen long muscles in shortened
range

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Stretching Suboccipitals/Scalenes

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Hypermobility
Excessive motion of the intervertebral segment.

Treatment
 Postural correction exercises.
 Consider taping of scapula to reduce pull on segment.
 Manually stabilize hypermobile segment or perform
cocontractions at involved levels.
 Gradually challenge cervical musculature while
preventing excessive motion at involved segment.

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Levator Scapula Stretch While
Stabilizing C4

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Posture Impairment
FHP
Treatment
 Lengthen short muscles
 Muscle imbalance
and strengthen weak
muscles
 Neuromeningeal  Side flexion and elevation
extensibility of scapula

 Articular hypomobility  Manual therapy and


mobility exercises
 Proprioception  Postural correction

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FHP – Axial Extension/Minimal
Lordosis/Excessive Lordosis

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Therapeutic Exercise Interventions for
Common Diagnoses
Disk Dysfunction
Changes in disk alter its biomechanical properties and
prevent normal function.

Treatment
 Initially aimed at rest positions
 Postural education (including pelvic girdle)
 Manual therapy to mobilize hypomobile segments
 Manual traction to decrease compression
 Stretching exercises during acute phase
 Progression of stabilization exercises for hypermobile segments

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Cervical Sprain and Strain
Most common incident is WAD after MVA

Treatment
 Proper resting position/postural education
 Ice/heat and therapeutic modalities to control
inflammation and pain
 Rhythmic neck rotations (supine)
 Subacute – Manual mobilization techniques
 Mobility exercises can slowly progress into larger
arc movements while maintaining postural integrity
 Specific strengthening exercises are introduced in
remodeling phase

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Neural Entrapment
Cervical nerve roots become entrapped at their
exit at the intervertebral foramen.

Treatment
Postural exercises/re-education
Address neuromeningeal hypomobility
Treatment of cervical/thoracic spine, shoulder
girdle, and wrist are common

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Cervicogenic Headache
Referred pain to head and/or face from first
three or four cervical nerves.

Treatment
Generalized ROM exercises for mobility
Specific muscle stretches (especially upper
cervical)
Exercises to increase muscle performance
of deep upper cervical flexors

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Summary

 CV complex includes AO and AA joints.


 Ligaments – Alar, transverse, tectorial membrane,
anterior/posterior AO membranes, posterior AA ligament.
 AO joint – Bicondylar, modified ovoid joint; two degrees
of motion (flexion/extension and combined side
flexion/rotation).
 AA joint – Multi-joint, complex, degrees of motion
(flexion/extension and combined side flexion/rotation).

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Summary (cont.)

 Midcervical joints – Zygapophyseal joints, UV joints,


interbody joints.
 Important midcervical ligaments – Anterior/posterior
longitudinal, ligamentum flavum, interspinous, and
ligamentum nuchae.
 Coordinated motion occurs among joints of midcervical
spine. Each segment – two degrees of motion
(flexion/extension and combined side flexion/rotation).
 Cervical spine exam and evaluation includes subjective
history, physical exam, vocational environment.

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Summary (cont.)

 Physical exam includes visual observation,


active/passive movement tests, myofascial and
neurological meningeal extensibility, MMT, neurologic
and clearing tests of thorax, shoulder girdle, and TMJ.
 Common physiologic impairments include muscle
performance, posture, mobility.
 A therapeutic exercise program is developed to address
each impairment and improve overall function.

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Summary (cont.)

 Common diagnoses of cervical spine are disk


dysfunction, sprain or strain, neural entrapment,
cervicogenic headache.
 For any patient presenting with a particular
diagnosis, impairments are identified and prioritized
according to those requiring immediate attention
and those most likely to be tolerated by the patient.

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Examination and Evaluation
Subjective

Onset of symptoms
Incidence of joint
locking
Presence of joint
noise
History of surgery
Pain (intensity,
frequency, location)
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Examination and Evaluation
Subjective

Onset of symptoms
Incidence of joint
locking
Presence of joint
noise
History of surgery
Pain (intensity,
frequency, location)
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Pain Examination (Palpation)

Tenderness, Warmth, and Inflammation

Mandible, hyoid, TMJ


Relevant joints of upper quadrant, cervical, and
upper thoracic spine
Muscles
Relevant trigger points and tender points of
fibromyalgia

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Mobility Impairment Examination

Active and passive physiologic ROM of


cervical and thoracic spine
TMJ: A/PROM – Vertical opening, lateral
excursion, protrusion
Joint function (TMJ translation and rotation)
Muscle tests (length, test, control)
Mobility of nervous system (if indicated)

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The Temporomandibular Joint

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Anatomy and Kinesiology

 Bones of skull, mandible, maxilla, hyoid, clavicle,


sternum, shoulder girdle, and cervical vertebrae
 TMJ and dentoalveolar joints (e.g., joints of teeth)
 Cervical spine
 Muscles and soft tissues of head and neck and muscles
of cheeks, lips, and tongue

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Stomatognathic System
Teeth

Muscles Joints

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Bones Movements of Mandible
 Mandible – Ramus and  Elevation
two condyles.  Depression
 Temporal bone – Articular  Protraction
tubercle, eminence,  Retraction
mandibular fossa,
posterior glenoid spine  Lateral gliding
 Hyoid bone.  Combinations of above

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TMJ – 2 Joints

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Muscles

Temporalis Mylohyoid
Masseter Genohyoid
Medial pterygoid Omohyoid
Lateral pterygoid
Digastric

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Muscles

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Tongue

Genioglossus is main muscle responsible for


positioning of tongue.
Active in protracting and elevating tongue.
Anterior open bite, airway compromise, etc. are
indicative of parafunctional habits (tongue thrust,
etc.).
Tongue position/habits will also influence
cervical spine.

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Kinetics

 TMJ, teeth, and cervical spine are intimately related.


 Cervical posture affects mandibular path of closure.

 Forward Head Posture (FHP) – 2 types

1. With posterior cranial rotation (PCR)


2. Without posterior cranial rotation

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FHP – With PCR and Without PCR

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Examination and Evaluation
Subjective

Onset of symptoms
Incidence of joint
locking
Presence of joint
noise
History of surgery
Pain (intensity,
frequency, location)
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Pain Examination (Palpation)

Tenderness, Warmth, and Inflammation

Mandible, hyoid, TMJ


Relevant joints of upper quadrant, cervical, and
upper thoracic spine
Muscles
Relevant trigger points and tender points of
fibromyalgia

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Mobility Impairment Examination

Active and passive physiologic ROM of


cervical and thoracic spine
TMJ: A/PROM – Vertical opening, lateral
excursion, protrusion
Joint function (TMJ translation and rotation)
Muscle tests (length, test, control)
Mobility of nervous system (if indicated)

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ROM Exercises

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Hypermobility

Heat and ice if condition is painful.

Muscle Performance

TMJ rotation and translation control.


Strengthening and stabilization exercises.
Isometric or static exercises.
Dynamic exercises.

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Isometric Stabilization

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Posture and Movement Impairments
 FHP with rounding of shoulders and TMJ
signs/symptoms.

Treatment

 Neuromuscular relaxation training.


 Head, neck, and shoulder postural training.
 Mandible and tongue postural exercises.
 Swallow sequence and breathing exercises.

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Derangement of the Disk
Anterior Dislocated Disk with Reduction

 Anterior repositioning appliance


 Non-repositioning appliance (flat plane splint)
 Heat, ice
 Education to relax muscles (SEMG feedback to
reduce muscle activity)

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TMJ Clicking

Lower jaw thrust


exercises
Noninvasive isometric
exercises
Mandibular stabilization
exercises

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Summary
 Relationships of stomatognathic system requires
a thorough evaluation and integrated treatment
approach.
 FHP affects the position of mandible, tongue,
hyoid, altering rest position, swallowing function,
airway, and muscle balance.
 Proper positioning of the tongue is essential to
maintain ideal resting position of mandible and
promotes normal swallowing function.

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Summary (cont.)

 Hypomobility of TMJ may result from various


conditions. Treatment seeks to reduce
inflammation and pain and to increase function.
 Hypermobility is usually bilateral; however, it
occurs unilaterally when there is a unilateral
restriction.
 Postoperative rehab can be 6–12 months.
Intervention includes reducing inflammation and
begin A/PROM.

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