Physical Therpay Protocols For Conditions of Neck Region

Red Flags for Potential Serious Conditions in Patients with Head and Neck Problems
Red Flags for the Head and Neck Region

Red Flag Red Flag
Condition Data obtained during Data obtained during
Interview/History Physical Exam
Subarachnoid Sudden onset of a severe headache Concurrent elevated blood pressure
Hemorrhage – History of hypertension Trunk and extremity weakness, Aphasia
Ischemic Stroke1,2 Altered mental status
Vertigo, Vomiting
Vertebrobasilar Dizziness Vertigo that lasts for minutes (not seconds)
Insufficiency3-5 Headaches Visual disturbances
Nausea Apprehension with end range neck movements
Loss of consciousness Unilateral hearing loss
Vestibular function abnormalities
Meningitis6,7 Headache Positive slump sign
Fever Photophobia
Gastrointestinal signs of vomiting and Confusion
symptoms of nausea Seizures
Sleepiness
Primary Brain Headache Ataxia
Tumor8-11 Gastrointestinal signs of vomiting and Speech deficits
symptoms of nausea Sensory abnormalities
Visual changes
Altered mental status
Seizures
Mild Traumatic Dangerous injury mechanism Loss of consciousness/dazed – an initial Glaslow
Brain Injury – Headache Coma Scale of 13 to 15
Post Concussion Nausea/vomiting Deficits in short term memory
Syndrome – Sensitivity to light and sounds Physical evidence of trauma above the clavicles
Subdural Drug or alcohol intoxication
Hematoma12,13 Seizures
References:
1. Hiroki O, Hidefumi T, Suzuki S, Islam S. Risk factors for aneurysmal subarachnoid hemorrhage in Aomori, Japan. Stroke.
2003;34:34-100.
2. Hong YH, Lee YS, Park S. Headache as a predictive factor of severe systolic hypertension in acute ischemic stroke. Can J
Neurol Sci. 2003;30:210-214.
3. Grad A, Baloh RW. Vertigo of vascular origin. clinical and electronystagmographic features in 84 cases. Arch Neurology.
46:281-4, 1989.
4. Szirmai A. Evidences of vascular origin of cochleovestibular dysfunction. Acta Neurol Scand. 2001;104:68-71.
5. Silbert PT, Bahram M, Schievink WI. Headache and neck pain in spontaneous internal carotid and vertebral artery
dissections. Neurology. 1995;45:1517-1522.
6. Hurwitz EL, Aker PD, Adams AH, et al. Manipulation and mobilization of the cervical spine: a systematic review of the
literature. Spine. 1996;21:1746-1760.
7. Bruce, M, Rosenstein N, Capparella J, et al. Risk factors for meningococcal disease in college students. JAMA. 2001;286:
688-693.
8. Berger JP. Buclin T. Haller E, et al. Does this adult patient have acute meningitis? JAMA. 1999;282:175-181.
9. Snyder H, Robinson K Shah D, et al. Signs and symptoms of patients with brain tumors presenting in the emergency
department. J Emerg Med. 1993;11:253-258.
10. Zaki A. Patterns of presentation in brain tumors in the United States. J Surg Oncology 1993; 53:110-112.
11. Forsyth PA, Posner JB. Headaches in patients with brain tumors: A study of 111 patients. Neurology. 1993; 43:1678-1683.
12. Sobri M, Lamont AC, Alias NA, Win MN. Red flags in patients presenting with headache: clinical indication for
neuroimaging. Brit J Radiology 2003; 76:532-535.
13. Borg J, Holm L, Cassidy JD, et al. Diagnostic procedures in mild traumatic brain injury: results of the WHO Collaborating
Centre Task Force on Mild Traumatic Brain Injury. J Rehabil Med. 2004; Suppl. 43: 61-75.
Joe Godges DPT, MA, OCS KP So Cal Ortho PT Residency

HEAD AND NECK SCREENING QUESTIONNAIRE
NAME: __________________________________________ DATE: _____________

Medical Record #: _________________________
Yes No
1. Are you currently being treated for high blood pressure?
2. Have you recently had difficulty with speaking?
3. Have you noticed an increased clumsiness or weakness in your arms or
legs?
4. Do you frequently have headaches?
5. Have you noticed a recent decreased ability of concentrate?
6. Do you experience dizziness?
7. Have you noticed a recent change in your vision or ability to see?
8. Have you recently experienced a blow to the head or a whiplash injury?
9. Have you been experiencing nausea and/or vomiting?
10. Do you currently have a fever, or have you had a fever recently?
11. Have you recently been living in close quarters, such as in a dormitory?
12. Do you have a depressed immune system?
13. Are your eyes sensitivity to light?
14. Have you recently had a seizure?
Joe Godges DPT, MA, OCS KP So Cal Ortho PT Residency

Cervical Spine Mobility Deficits
ICD-9-CM code: 723.1 Cervicalgia
ICF codes: Activities and Participation Domain code: d4108 Changing a basic
body position, other specified - specified as: rotating the
head and neck, such as in looking to the left or to the right
Body Structure code: s76000 Cervical vertebral column
Body Functions code: b7101 Mobility of several joints
Common Historical Findings:

Neck pain, usually unilateral, pain referral from base of occiput to scapular region (location
of pain referral is dependent upon which segment or segments are involved)
Strain; awkward, unguarded movement; or prolonged period of time in strained position
("Woke up with pain")
Common Impairment Findings - Related to the Reported Activity Limitation or Participation Restrictions:
Increase in pain at end range of rotation left or rotation right
Symptoms reproduced with palpation of the involved facet
Motion limitation and pain at end range of either anterior/superior glide or
posterior/inferior glide of the involved spinal segment
Physical Examination Procedures:
Cervical Accessory Movement Test

Anterior/Superior Glide
Joe Godges DPT, MA, OCS 1 KP So Cal Ortho PT Residency

Anterior/Superior Glide
Performance Cues:
Use DIP, PIP, or MCP for contact
Use a "Flat Hand" - whole palm contacting side of neck and head
Slowly and predictably sink through the skin and myofascia until contact with "articular
pillars" is made
Pull the top half of the "pea-sized" facet "toward the eyes" (ok to facilitate rotation to the
opposite side of facet being assessed)
Assess mobility, resistance to movement, and symptom response of C2-3, C3-4, C4-5,
C5-6, and C6-7

Posterior/Inferior Glide
Performance Cues:
Use PIP or MCP contact; flat, soft hand; predictable, uniform movement; sink through
soft tissue

Push the top half of the facet down and back (ok to facilitate side bending to same side of
facet being assessed)
Assess mobility, resistance, and symptom response of each segment
Cervical Spine Mobility Deficits: Description, Etiology, Stages, and Intervention Strategies
The below description is consistent with descriptions of clinical patterns associated with the vernacular term
“Cervical Facet Syndrome”
Description: Dysfunction of the movement of the one vertebrae of the cervical spine relative to
its adjacent vertebrae. This is usually a result of muscle imbalances, facet irregularities or
trauma. Patients with this condition commonly complain of unilateral neck and upper back pain
that increases at the end ranges of left or right sidebending or rotation. And, repeated flexion and
extension movements do not improve or worsen the patient’s baseline level of pain
Etiology: The cause of this dysfunction is believed to be a movement abnormality where a

segment of the spine is unable to either flex, extend, side bend or rotate normally in a pain free
manner on its adjacent vertebrae. This movement abnormality can be caused by either a
displacement of fibro-fatty tissue within the outer borders of the facet capsule or posttraumatic
fibrosis of the facet capsule. The cause of the movement abnormalities and the associated pain is
thought to be a sudden, awkward, twisting or bending motion. This results in a potentially
reversible displacement of fibro-fatty tissue. The cause could also be a mild joint contracture
following the fibrotic healing of a posttraumatic facet capsule.
Acute Stage / Severe Condition: Physical Examinations Findings (Key Impairments)

ICF Body Functions code: b7101.3 SEVERE impairment of mobility of several joints
• Unilateral posterior-to-anterior pressures at the involved segment reproduce the

patient’s pain complaint
• Motion restrictions are present at the involved segment
• Myofascia associated with the involved segment is usually hypertonic and painful
Sub Acute Stage / Moderate Condition: Physical Examinations Findings (Key Impairments)
ICF Body Functions code: b7101.2 MODERATE impairment of mobility of several joints
As above with the following differences:
• The patient’s unilateral symptoms are reproduced only with overpressures at end
ranges of left or right sidebending
Note: Improved segmental mobility is commonly associated with improving
symptomatology
Settled Stage / Mild Condition Physical Examinations Findings (Key Impairments)

ICF Body Functions code: b7101.1 MILD impairment of mobility of several joints

• The patient’s unilateral symptoms are reproduced only with end range overpressures
in either a combined extension and sidebending motion or a combined flexion and
sidebending motion
Now when the patient is less acute examine for muscle flexibility and strength
deficits that may be a predisposing factor for future injury. For example:
• Muscles that commonly exhibit flexibility deficits in patients with facet abnormalities
are middle and posterior scaleni, SCM, upper trapezius, and the myofascia associated
with the involved cervical segment
• Muscles that are commonly weak are the cervical neck flexors (i.e., longus colli),
upper thoracic extensors and scapular retractors/adductors (i.e, middle and lower
trapezius)
Intervention Approaches / Strategies
Acute Stage / Severe Condition
Goal: Restore painfree active spinal mobility
• Physical Agents
Ice (or heat) to provide pain relief and reduce muscle guarding
• Manual Therapy
Soft tissue mobilization to the myofascia associated with the involved cervical
segment
Isometric mobilization and contract/relax procedures to the involved segment to
reduce muscle guarding
Passive stretching procedures to restore normal cervical segmental mobility
• Therapeutic Exercises
Instruction in exercise and functional movements to maintain the improvements in
mobility gained with the soft tissue and joint manipulations
Strengthening exercises for the neck flexors

• Re-injury Prevention Instruction
Instruct the patient in efficient, painfree, motor performance of movements that
are related by the patient to be the cause of the current episode of neck pain
Sub Acute Stage / Moderate Condition:
Goal: Restore normal, painfree response to overpressures at end ranges of cervical rotation and
sidebending
• Approaches / Strategies listed above – focusing on:
• Manual Therapy
Soft tissue mobilization and joint mobilization/manipulation to normalize the
segmental mobility
Note: Performing upper cervical joint mobilization/manipulations with the

patients upper cervical spine at end ranges of extension or the end ranges of
combined of extension/rotation movements is contraindicated due the
potential disastrous effects that these manipulative procedures have been
reported to have on some individual’s vertebral artery. Thus, all upper
cervical manipulations are performed with the head and neck in the neutral
or flexed position
Instruction in exercise and functional movements to maintain the improvements in
mobility gained with the soft tissue and joint manipulations (e.g., towel SNAGs)
Settled Stage / Mild Condition:
Goals: Restore normal, pain free responses to overpressures of combined extension and
sidebending/rotation and/or combined flexion and sidebending/rotation
Normalize cervical and upper thoracic flexibility and strength deficits
• Approaches / Strategies listed above
Stretching exercises to address the patient’s specific muscle flexibility deficits
Strengthening exercises to address the patient’s specific muscle strength deficits

Intervention for High Performance / High Demand Functioning in Workers or Athletes
Goal: Return to desired occupational or leisure time activities
Encourage participation in regular low stress aerobic activities as a means to
improve fitness, muscle strength and prevent recurrences
• Ergonomic Instruction
Provide body mechanics instructions and modify work area as indicated to
prevent symptoms. This typically emphasizes neutral cervical position for sitting,
driving, traveling as a passenger in a car, bus, or airplane, reading, eating, and
resting/sleeping.
Selected References
Di Fabio RP. Manipulation of the cervical spine: risks and benefits. Phys Ther. 1999;79:50-65.
Jackson RP. The facet syndrome: myth or reality? Clin Orthop Rel Res. June, 1992.
Taimela S, Takala E, Asklof T, Seppala K, Parvianen S. Active treatment of chronic neck pain. a
prospective randomized intervention. Spine. 2000;25:1021-1027.
Jull G, Trott P, Potter H, Zito G, Niere K. Shirley D, Emberson J, Marschner I, Richardson C. A

randomized controlled trial of exercise and manipulative therapy for cervicogenic headache.
Spine. 2002;27:1835-1843.

Posterior Cervical Myofascia
Soft Tissue Mobilization
Suboccipital Myofascia
Soft Tissue Mobilization

Impairment: Limited and Painful Cervical Flexion, Right Rotation or Right Sidebending
Cervical NAG
Cues: Hug the patient’s head with your right forearm and anterior lateral trunk
It usually helps to be in front of the patient’s shoulder
The 5th finger of right hand is the “dummy” finger positioned on the spinous process or
articular pillar
Provide traction or other combined movements by weight shifting to the backward (right)
leg
Mobilize in the direction of the facet plane (superiorly more than anteriorly) using the left lateral
wrist/thenar eminence to provide the force
Generate the superior-anterior glide using left elbow flexion
“Catch” the skin with the “dummy” finger a segment of two below the involved
If the procedure is painful, stop. Consider naging in a slight different treatment plane or
on a different cervical segment
The following reference provides additional information regarding this procedure:

Brian Mulligan MNZSP, DipMT: Manual Therapy, p. 12-15, 1995

Impairment: Limited and Painful Cervical Right Rotation
Cervical SNAG
Cues: Use the right thumb as the “dummy” thumb over either the spinous process or the
articular pillar
The left thumb provides the SNAG
Sustain the NAG pressure in the plane of the facet – think superiorly more than anteriorly
Remember: 1) NAG, 2) Sustain the NAG, 3) Overpressure end range, 4) Sustain the NAG during
left rotation back to neutral, 5) Release NAG
Use the ulnar aspect of the left hand or little finger, if possible, to limit thorax right rotation by
manually cuing the anterior aspect of the left clavicle
Remember: A SNAG is indicated if it permits (and improves) painfree motion
Alteration of the direction of the active cervical motion while performing this SNAG can also be
used to treat limited and painful cervical sidebending, extension, or flexion

Brian Mulligan MNZSP, DipMT: Manual Therapy, p. 18-25, 1995

Impairment: Limited Cervical Segmental Sidebending/Rotation
Cervical Superior/Anterior Glide
Cues: Contact the articular pillar of the superior vertebrae of the involved segment and glide it
“toward the eyes”
Stabilize the vertebrae below by contacting its spinous process (i.e., stablize the right side
of the spinous process of C6 with the left middle finger as the right middle finger
contacts the posterior aspect of the right C5 articular pillar and provides a
superior/anterior glide of C5)
Utilize this procedure to address both the segmental myofascia and joint mobility deficits

Freddy Kaltenborn PT: The Spine: Basic Evaluation and Mobilization Techniques, p. 260, 1993
Impairment: Limited Cervical Segmental Rotation
Cervical Rotation in Neutral

Cues: Assess the amplitude (and end feel) of cervical rotation (using an anterior/superior glide)
of the involved segment in neutral
Add combined movements of cervical sidebending, side gliding, slight anterior (or
posterior) gliding, slight extension (or flexion), traction, and compression (firm
“hug” of the head and neck), until the anterior/superior glide motion barrier (i.e.,
end feel) is as “crisp” as possible
Mobilize (or manipulate) with a low amplitude force into this barrier

Laurie Hartman DO: Handbook of Osteopathic Technique, p. 171-172, 1997

Impairment: Limited Cervical Segmental Flexion, Right Sidebending, and Right Rotation
Cervical Spine Contract/Relax

(of segmental extensors and left sidebenders)
Cues: “Slump the cervical spine as best as possible to create the maximal available posterior
translation of the involved segment
Maintaining the posterior “slump”, translate the involved segment to the left to obtain the
maximal available lateral translation
The intention is to create an apex of both posterior translation and left lateral translation
at the involved segment, thus, placing the involved facet capsule and its
associated segmental myofascia at end range
Elicit contraction of the left sidebenders and/or left extensors – relax – take up slack –
repeat
Use a soft and “flat” manual contact to avoid painful pressure with the right hand
Utilize “traction” with the left hand to enhance the sidebending stretch to the left facet
joints and myofascia
The following references provides additional information regarding this procedure:

John Bourdillon FRCS, EA Day MD, and Mark Bookhout MS, PT: Spinal Manipulation, p. 260,
1992
Philip Greenman DO, FAAO: Principles of Manual Medicine, p. 191, 1996

Impairment: Limited Cervical Segmental Flexion, Right Sidebending, and Right Rotation
Cervical Right Sidebending/Rotation in Flexion
Cues: At the end range of both posterior and lateral translation barriers - apply low amplitude
mobilizations or a low amplitude manipulation into the barrier
The direction of the mobilization force is laterally (“to open the joint on the opposite
side”)
Comfort and effectiveness is increased if: 1) the right hand maintains a broad surface
contact, and 2) the left hand applies a “traction” force to maintain the stretch to
the left cervical facets and segmental myofascia


Impairment: Limited Cervical Segmental Extension, Right Sidebending, and Right Rotation
Cervical Spine Contract/Relax

(of segmental flexors and left sidebenders)
Cues: Use the index finger of the right hand to anterior glide, then, left laterally translate the
involved segment
Elicit contraction of the left sidebenders and/or flexors of the involved segment - relax –
take up slack in both “barriers” – repeat

John Bourdillon FRCS, EA Day MD, and Mark Bookhout MS, PT: Spinal Manipulation, p. 257-
259, 1992
Philip Greenman DO, FAAO: Principles on Manual Medicine, p. 189-190, 1996
Cervical Sidebending/Rotation in Extension
Cues: At the end range of both anterior and lateral translation barriers - apply low amplitude
mobilizations or a low amplitude manipulation into the barrier
The direction of the mobilizing is primarily inferiorly (“to close the joint on the same side”)

John Bourdillon FRCS, EA Day MD, and Mark Bookhout MS, PT: Spinal Manipulation, p.261, 1992
Philip Greenman DO, FAAO: Principles on Manual Medicine, p. 196, 1996

Impairment: Limited C1/C2 Right Rotation
C1/C2 Contract/Relax
Cues: Fully flex C2 through C7
Adding flexion at the occiput/C1/C2 areas assists in preventing rotation past C2 (i.e., it
helps create a “firm” C1/C2 rotation barrier)
Rotate occiput and C1 to the right until the first “barrier” - be sure to 1) maintain the
cervical flexion, and 2) prevent cervical sidebending
“Look with your eyes to the left” – Relax – Take up the now available right rotation slack
passively (or “gently look to the right”) - relax - repeat contract/relax procedures
3 to 5 times

264, 1992

C1/C2 Rotation
Cues: Stabilize the right lamina of C2 with your left thumb

Comfortably hug the patient’s head and rotate it (with C1) to the right
Tilt the head to the left to allow some slack in the left alar ligament
Apply a passive stretch (or, a contract/relax stretch)
Be especially tuned into the patient with regards to VBI symptoms or signs while
performing this technique
The following reference provides additional information regarding a similar procedure:


Impairment: Limited Occiput/C1 flexion
Limited Occipital Posterior Glide (or C1 Anterior Glide) on the Left
Occipital Posterior Glide
Cues: Rest the right middle finger on the left thenar eminence
Position the patient (and your hands) so that the left lateral mass of C1 is contacted by the
“dummy” middle finger
Apply a posterior glide to the left occipital condyle via a posterior force on the patients
left forehead (using flexion of your thorax – with your left anterior
deltoid/clavipectoral area contacting the patient’s left forehead)
C1 Anterior Glide

Impairment: Limited Upper Cervical Right Sidebending
Limited C1 Right Lateral Translation
C1 Lateral Translation
Cue: Contact the left C1 lateral mass with 1) your left index or middle finger, or 2) the radial
side of your left index finger MCP area
Stabilize the skull with your right hand
Apply right lateral translatory oscillations or stretching forces to C1
Be kind and gentle - but effective
Don’t be in a hurry
The following reference provides additional information regarding similar procedures:

Freddy Kaltenborn PT: The Spine: Basic Evaluation and Mobilization Techniques, p. 243, 277,
1993

Impairment: Limited Occipital Flexion and Right Sidebending
Occiput/C1 Contract/Relax
Cue: Nod the occiput to take up the flexion barrier

Translate the nodded occiput to the left to first upper cervical barrier – not mid cervical
barrier
Keep the eyebrows parallel to the transverse plane when translating the occiput (to avoid
inadvertent left sidebending)
Elicited contraction of the segmental extensors (“look to the left”)
Manually cue either the anterior aspect of the chin or the left zygoma (with your left
forearm) when providing the verbal commands
Maintain both the flexion and the left translation barriers during the contraction
Relax
Take up available slack in both barriers
Repeat

268, 1992

Occipital Distraction in Flexion and Sidebending
Cues: Contact the right occipital condyle with the anterior surface of the index finger
metacarpal of the right hand
As best as possible, align your right forearm parallel to the distraction force direction
“Hug” the right side of patient’s head with your left forearm
Position the patient at the barriers of both flexion and left translation - as he/she exhales
The distraction mobilization or manipulation force primarily comes from your index
finger metacarpal – using a weight shift from your trunk
If you are not moving the patient’s feet (“positive toe sign”) you are probably not
providing enough traction force to distract the patient’s occiput from C1

269, 1992

Impairment: Limited Occipital Extension and Right Sidebending
Occiput /C1 Contract/Relax

Cues: Extend the head (not the cervical spine) to take up the extension barrier
Translate the extended head to the left to the first (upper cervical - not mid cervical) barrier
Translate left - not sidebend left
Elicit contraction of the segmental flexors (“look down toward your feet”) or sidebenders
(“look to the left)
Manually cue either under the chin or the left zygoma when providing the verbal
commands
Maintain both barriers during the contraction
Relax - take up slack – repeat

John Bourdillon FRCS, EA Day MD, M Bookhout MS, PT: Spinal Manipulation, p. 266, 1992
Occipital Distraction in Extension and Sidebending
Cues: Contacts and force application is similar to the occipital distraction in flexion
Position the patient at the barriers of occipital extension (not cervical extension) and left
translation - as he/she exhales
Maintain these barriers – apply the distraction mobilizations or manipulation

John Bourdillon FRCS, EA Day MD, M Bookhout MS, PT: Spinal Manipulation, p.268, 1992

Cervical Spine Movement Coordination Deficits
ICD-9-CM code: 847.0 Neck ligament sprain
ICF codes: Activities and Participation Domain code: d4159 Maintaining a body position,
unspecified
Body Structure code: s76000 Cervical vertebral column
Body Functions code: b7601 Control of complex voluntary movements

Significant trauma (e.g., MVA, fall, blow to head)
Muscle “tightness” or “spasm”
Pain with mid-range motions - increases at end range of painful motion
Tender with palpation of area (ligamentum nuche, spinous process and interspinous
space) of the involved segment(s)
Pain with central posterior-to-anterior PA pressures
If upper cervical ligament strain: laxity and/or symptom alteration with ligaments
stability exam
Palpation of Midline Soft Tissue

Central Posterior-to-Anterior Pressures
Performance Cues:
May need to slightly flex head and neck to differentiate segments
Support head and neck to limit muscular contraction
Palpate areas near ligamentum nuche, spinous processes, and interspinous spaces –
determine symptom response

Alar Ligament Integrity Test Alar Ligament Integrity Test
Performance Cues:
Keep head supported to limit muscle guarding
Place head and neck in midline
Pinch C2 spinous between left thumb and index finger
Side bend skull 10-15 degrees to the right
Normal - lateral aspect of the C2 spinous immediately moves into thumb
Abnormal - the C2 spinous process does not move or the movement is noticeably delayed
as the head is sidebent
Involuntary or voluntary muscle guarding may produce false negative results to these
examination procedures
Sharp-Purser Test for Ligamentus

Integrity for the Transverse Ligament
Performance Cues:
Flex skull slightly while sitting - about 25 degree or until the motion is “taken up” - do not take
up slack in tissues below C2.
In the abnormal - head flexion allows the occiput and C1 vertebrae to translate anteriorly
relative to C2. Thus, this position may provoke symptoms.
Posteriorly translate the skull-with the head in slight flexion - while stabilizing the spinous
process of C2 with an anteriorly directed force
In the abnormal - relative posterior translation of the skull in noted (approximately 5mm).This
position may alleviate the patient’s symptoms
In the normal - no symptoms are produced with head flexion and no translatory motion is
detected with occiput/C1 (posteriorly directed) translation (while C2 is stabilized)
The stabilization (anteriorly directed) force of C2 is firm

Cervical Spine Stability Deficits: Description, Etiology, Stages, and Intervention Strategies
“Cervical Instability or Cervical Ligament Strain”
Description: A sudden jerky movement, “whiplash” to the neck, or blow to the head could lead
to cervical ligament sprain. Pain is usually felt in the back of the neck that gets worse with
movement. Muscle spasms and pain are the common complaint. The pain may be referred to
the upper back, shoulder girdle or upper extremity. The pain may be more noticable a day after
the injury. The pain symptoms worsen with movement. Headaches, increased fatigue,
irritability, and restless sleep are also associated with this disorder.
Etiology: The cause of this disorder could be due to significant trauma such as car crash, or
applying sudden brakes in which the head goes backward while the body stays back due to the
seat belt. This causes head and neck to extend and get overstretched causing stress on the
ligaments of the neck. Contact sports are also a common cause of cervical ligament sprains.
Individuals with a long history of a collagen vascular disease, such as rheumatoid arthritis, may
have upper cervical ligamentous instability as an unfortunate consequence of their disease.
Physical Examinations Findings (Key Impairments)

ICF Body Functions code: b7601.3 SEVERE impairment of motor control/coordination
of complex voluntary movements
• Pain with end range cervical motion
• May have swelling or bruising at the injury site
• Muscle spasms at the associated spinal segment
• Central or unilateral posterior-to-anterior pressures reproduce the reported symptoms
• May exhibit laxity with ligamentous integrity tests (e.g., alar ligament integrity test or
the Sharp-Purser test)
ICF Body Functions code: b7601.2 MODERATE impairment of motor
control/coordination of complex voluntary movements
• As above – the severity of the tenderness and muscle guarding may resolve at a slow
rate if the injury was significant.
• Be cautious of an underlying instability that is potentially dangerous to the patient’s
neural structures. Muscle guarding at the segment may mask this instability.
• Weakness of neck musculature, especially the neck flexors
Settled Stage / Mild Condition: Physical Examinations Findings (Key Impairments)

ICF Body Functions code: b7601.1 MILD impairment of motor control/coordination of
complex voluntary movements

• Symptoms worsen or peripheralize with sustained end range positions or with
repeated movements into the patient’s available range
Goals: Allievate pain while in neutral cervical positions

Prevent further stress on injured tissues

Limit active and passive movement to painfree ranges
Instruction is proper neutral positions for common activities such as sleeping,
sitting, reading, driving, and eating, as well as for movements such as moving
from supine to a sitting position
• External Devices (Taping/Splinting/Orthotics)

A rigid cervical collar is often indicated for acute cervical sprains to limit further
stress on the damaged tissues
A soft cervical collar may be useful in less severe strains to cue the patient to
maintain the neutral position
• Physical Agents
Ice packs applied with the neck in a neutral position may by applied for 15-30
minutes every few hours to reduce pain and inflammation
Sub Acute Stage / Moderate Condition
Goals: Prevent re-injury

Strengthening of neck musculature to improve dynamic stability
Improve mobility in areas superior or inferior to the injured, hypermobile segment
Initiate cervical stabilization/strengthening program – with emphasis on the deep
cervical neck flexors (i.e., longus colli)
• Manual Therapy
Soft tissue and joint mobilization to restricted segments in the upper thoracic,
mid-cervical, or upper cervical region. Caution not to mobilize any segment
that is potentially hypermobile or unstable.
Promote efficient, painfree, motor control of the neck, scapulae and arm
Modify activities to prevent overuse and re-injury

Modify workstation to reduce risk of mounting pressure on the neck

Emphasize the importance of neutral posture
Emphasize the importance of maintaining adequate stabilization through muscular
control of the unstable segment – especially in individuals who participate in
contact sports or other activities involving potential stress to the cervical spine.
Settled Stage / Mild Condition
Goal: Progress activity tolerance
• Approaches/ Strategies listed above
Provide endurance training to maximize muscle performance of the neck,
scapulae, and shoulder girdle muscles required to perform the desired
occupational or recreational activities
Intervention for High Performance / High Demand Functioning in Workers or Athletes
Add job/sport specific training
Selected References
Donatelli, Robert. Orthopedic Physical Therapy. Georgia: Churchhill Livingstone Inc. 1994.
Gennis P, Miller L, Gallagher J, et al: The effect of soft cervical collars on persistent neck pain
in patients with whiplash injury. Acad Emerg Med 3:568-573, 1996.
Magee, David. Orthopedic Physical Assessment. Pennsylvania: W.B. Saunders Co. 1997.
Meadows J: The Role of Mobilization and Manipulation in treatment of Spinal Instability. J

Orthop Phys Ther Clin N Am 8:519-34, 1999.
O’Grady WH, Tollan MF: The role of exercise in the treatment of instabilities of hypermobilities
in the cervical spine. Orthop Phys Ther Clin N Am 10:3, 475-501, 2001.
Swinkles-RAH, Oostendorp-RAB: Upper cervical instability: fact or fiction? Journal of

Manipulative and Physiological Therapeutics 19:185-94, 1996.

Neck and Headache Pain
ICD-9-CM code: 723.2 cervicocranial syndrome
ICF codes: Activities and Participation Domain code: d4158 Maintaining a body position,
other specified - specified as: maintaining the head in a
flexed position, such as when reading a book; or,
maintaining the head in an extended position, such as when
looking up at a computer screen or video monitor
Body Structure codes: s7103 Joints of head and neck region
Body Functions code: b28010 Pain in head and neck

Unilateral neck pain with referral to occipital, temporal, parietal, frontal or orbital areas
Headache precipitated or aggravated by neck movements or sustained positions
Noncontinuous headaches (usually < 1 episode/day; < 2 episodes/week)
Observable postural asymmetry of the head on neck (sidebent or extended)
Headache reproduced with provocation of the involved segmental myofascia and/or joints
O/C1, C1/C2, or C2/C3 restricted accessory motions with associated myofascial trigger
points
Palpation/Provocation of Suboccipital Myofascia

O/C1, C1/C2, or C2/C3 accessory motion testing
using posterior-to-anterior pressures
0/C1 accessory motion testing

using C1 lateral translatoty pressures
C1 – C2 Rotation ROM testing

with the C2 – C7 segments in flexion

Neck and Headache Pain: Description, Etiology, Stages, and Intervention Strategies
The below description is consistent with descriptions of clinical patterns associated with the term
“Cervicogenic Headache.”
Description: Cervicogenic headache is a headache where the source of the ache is from a
structure in the cervical spine, such as a cervical facet, muscle, ligament, or dura. The pain is
referred to the occipital, temporal, parietal, frontal, and orbital areas. The characteristics of
cervicogenic headache are unilateral dominant side-consistent headache associated with neck
pain and aggravated by neck postures or movement, limited range of motion in the cervical spine
and joint tenderness in at least one of the upper three cervical joints as detected by manual
palpation. The aching is moderate-severe, without throbbing or lancinating pain, usually starting
in the neck. The episodes can be of varying duration (few hours to a few weeks). The initial
phase of cervicogenic headache is usually frequent and episodic. The occurrence among females
is twice that of males.
Etiology: The headache is due to a musculoskeletal disorder in the upper cervical spine. Thus,
movement stresses of the upper cervical spine are associated with the headache complaint (e.g.,
headache is worse at the end of a days work at a computer screen or talking on the phone).

ICF Body Functions code: b28010.3 SEVERE pain in head and neck joints
• Abnormal head on neck posture is commonly observed (e.g., the head is held in an
excessively extended position or an excessive sidebent position relative to the upper
cervical segments)
• Limited O-C1 and/or C1-C2 and/or C2-C3 segmental mobility
• Headache aggravated with certain head positions or sustained movements
• Headaches reproduced with provocation of the involved segment at O/C1, C1/C2, C2/C3
or with provocation of trigger points in the suboccipital myofascial or during slump
testing of the dural elements
• Deep cervical flexor muscle control deficits (i.e., rectus capitus anterior and longus colli)
ICF Body Functions code: b2801.2 MODERAT pain in head and neck joints
• As above – the ability to reproduce the patient’s headache via palpatory provocation of
the involved joints or myofascial lessens as the mobility of the involved upper cervical
segments
Settled / Moderate Condition: Physical Examinations Findings (Key Impairments)

ICF Body Functions code: b2801.1 MILD pain in head and neck joints
Now when the patient is less acute examine for ergonomic factors, postural habits,
muscle flexibility and strength deficits that may be predisposing factors for upper cervical
somatic disorders. For example:

• Ergonomic or postural paterns that involve excessive thoracic kyphosis and associated
excessive cervical lordosis predisposes the head to be excessively extended on the neck –
placing the upper cervical extensors on a chronically shortened position – thus,
precipitating the above listed impairments.
• Upper quarter muscle imbalances such as tightness of the scapular elevators (i.e., levator
scapulae and upper trapezius) muscles and weakness of the scapular adductors/stabilizing
(i.e., lower and middle trapezius) muscles
Acute stage / Severe Condition
Goals: Reduce the frequency and severity of the headaches

Reduce the medication required to manage the symptoms

Avoid positions that reproduce or aggravate the headaches
• Manual Therapy
Soft tissue mobilization to the involved suboccipital myofascial restrictions
(performed at an intensity that does not aggravating the patient’s condition)
Joint mobilization/manipulation to the involved upper cervical facet restrictions
(performed at an intensity or velocity that does not aggravating the patient’s
condition)
Note: Performing upper cervical joint mobilization/manipulations with the

patients upper cervical spine at end ranges of extension or the end ranges of
combined of extension/rotation movements is contraindicated due the
potential disaterous effects that these manipulative procedures have been
reported to have some individual’s vertebral artery. Thus, all upper cervical
manipulations are performed with the head and neck in the neutral or flexed
position
• Therapeutic Exercise:
Instruct in exercise and functional movements to maintain the improvements in
mobility gained with the soft tissue and joint manipulations (Head nodding and
retraction/protraction for O-C1 and rotation for C1-C2)
• Ergnomics Instructions
Postural re-education to limit excessive extended head postitions during
occupational tasks, recreational activities and other daily activities
Sub Acute Stage / Moderate Condition

Goals: As above
Normalize upper cervical segmental mobility
• Approaches / Strategies listed above – focusing on restoring normal, pain free

occipital and cervical spine mobility.
• Therapeutic Exercise
Low load endurance exercises to train muscle control of the cervical and scapular
region, consists of exercises targeting deep neck flexor muscles and longus
capitus and colli, trapezius, and serratus anterior. For example, cervical flexion
exercises using a pressure biofeedback unit and isometric exercises using rotatory
resistance to train the cocontraction of the neck flexors and extensors
Settled Stage / Mild Condition
Goals: As above
Normalize cervical and upper thoracic flexibility and strength deficits
Increase activity tolerance
Dural mobiliy exercises to address the patient’s specific dural mobility deficits
Intervention for High Performance/High Demand Functioning in Workers or Athletes
Maximize muscle performance of the neck, scapulae, shoulder girdle muscles
perform the desired occupational or recreational activities.

Selected References
Bansevicius D, Sjaastad O. Cervicogenic headache: The influence of mental load on pain level
and EMG of shoulder-neck and facial muscles. Headache. 1996;36:372-8.
Bovim G, Berg R, Dale LG. Cervicogenic headache: Anesthetic blockades of cervical nerves
(C2-C5) and facet joint (C2-C3). Pain. 1992;49:315-20.
Jull G, Trott P, Potter H, Zito G, Niere K, Shirley D, Emberson J, Marschner I, Richardson C. A

randomized controlled trial of exercises and manipulative therapy for cervicogenic headache.
Spine. 2002;27:1835-43.
Mulligan BR. Manuel Therapy ‘Nags’, ‘Snags’, ‘MWMs’ etc. 4th ed. Wellington: Plane View
Press, 1995
Nilsson N. The prevalence of cervicogenic headache in a random population same of 29-to 59-
year-olds. Spine. 1995;20:1884-8
Petersen S. Articular and Muscular Impairments in Cervicogenic Headache: A Case Report.

Journal of Orthopedic Sports Physical Therapy. 2003;33:21-32.
Sjaastad O, Fredriksen TA, Pfaffenrath V. Cervicogenic headache: Diagnostic criteria. Headache

1998;38:442-5.

MANUAL EXAMINATION AND TREATMENT OF THE UPPER CERVICAL SPINE
Symptoms/Signs of Cerebral Anoxia:

Apprehension, anxiety, or panic with cervical movements
Vertigo and dizziness
Blurred vision
Nystagmus
Nausea
Slowness of Response
Manual Examination:
If hypermobility is suspected, examine for instability:

Sharp-Purser Test
Odontoid-Alar Ligament Test
Hypermobile accessory movements
Central tenderness or pain with central posterior-to-anterior pressures
If vascular insufficiency is suspected:

Watch for signs of cerebral anoxia
Perform vertebral artery tests – continually assessment of symptoms/signs of cerebral anoxia
Passive Movements:
Physiological Movement Testing:
Occiput-C1: Occiput FB/BB
Occiput SB
Occiput Lateral Translatory Movements in FB and BB
C1-C2: A/A Rotation in cervical flexion
Accessory Movement Testing:

Occiput-C1: C1 Anterior Glide
C1 Lateral Glide
Palpation:
Sub-occipital myofascia
Manual Treatment
Soft Tissue Mobilization:

Sub-occipital myofascia STM
Contract-Relax
Occiput-C1
C1-C2
Passive Joint Mobilization:

Occipital Distraction
C1 Anterior Glide
C1 Lateral Glide
C1-C2 Rotation (sitting)
Re-Education:
Neutral Head/Neck Cueing
Neck Flexor Therapeutic Exercises
Always remember: While performing all examination and treatment procedures, be alert for signs of cerebral anoxia

C1/C2 Contract/Relax
Cues: Fully flex C2 through C7
Adding flexion at the occiput/C1/C2 areas assists in preventing rotation past C2 (i.e., it
helps create a “firm” C1/C2 rotation barrier)
Rotate occiput and C1 to the right until the first “barrier” - be sure to 1) maintain the
cervical flexion, and 2) prevent cervical sidebending
“Look with your eyes to the left” – Relax – Take up the now available right rotation slack
passively (or “gently look to the right”) - relax - repeat contract/relax procedures
3 to 5 times

264, 1992

C1/C2 Rotation
Cues: Stabilize the right lamina of C2 with your left thumb

Comfortably hug the patient’s head and rotate it (with C1) to the right
Tilt the head to the left to allow some slack in the left alar ligament
Apply a passive stretch (or, a contract/relax stretch)
Be especially tuned into the patient with regards to VBI symptoms or signs while
performing this technique
The following reference provides additional information regarding a similar procedure:


Impairment: Limited Occiput/C1 flexion
Limited Occipital Posterior Glide (or C1 Anterior Glide) on the Left
Occipital Posterior Glide
Cues: Rest the right middle finger on the left thenar eminence
Position the patient (and your hands) so that the left lateral mass of C1 is contacted by the
“dummy” middle finger
Apply a posterior glide to the left occipital condyle via a posterior force on the patients
left forehead (using flexion of your thorax – with your left anterior
deltoid/clavipectoral area contacting the patient’s left forehead)
C1 Anterior Glide

Impairment: Limited Upper Cervical Right Sidebending
Limited C1 Right Lateral Translation
C1 Lateral Translation
Cue: Contact the left C1 lateral mass with 1) your left index or middle finger, or 2) the radial
side of your left index finger MCP area
Stabilize the skull with your right hand
Apply right lateral translatory oscillations or stretching forces to C1
Be kind and gentle - but effective
Don’t be in a hurry
The following reference provides additional information regarding similar procedures:

Freddy Kaltenborn PT: The Spine: Basic Evaluation and Mobilization Techniques, p. 243, 277,
1993

Occiput/C1 Contract/Relax
Cue: Nod the occiput to take up the flexion barrier

Translate the nodded occiput to the left to first upper cervical barrier – not mid cervical
barrier
Keep the eyebrows parallel to the transverse plane when translating the occiput (to avoid
inadvertent left sidebending)
Elicited contraction of the segmental extensors (“look to the left”)
Manually cue either the anterior aspect of the chin or the left zygoma (with your left
forearm) when providing the verbal commands
Maintain both the flexion and the left translation barriers during the contraction
Relax
Take up available slack in both barriers
Repeat

268, 1992

Occipital Distraction in Flexion and Sidebending
Cues: Contact the right occipital condyle with the anterior surface of the index finger
metacarpal of the right hand
As best as possible, align your right forearm parallel to the distraction force direction
“Hug” the right side of patient’s head with your left forearm
Position the patient at the barriers of both flexion and left translation - as he/she exhales
The distraction mobilization or manipulation force primarily comes from your index
finger metacarpal – using a weight shift from your trunk
If you are not moving the patient’s feet (“positive toe sign”) you are probably not
providing enough traction force to distract the patient’s occiput from C1

269, 1992

Impairment: Limited Occipital Extension and Right Sidebending
Occiput /C1 Contract/Relax

Cues: Extend the head (not the cervical spine) to take up the extension barrier
Translate the extended head to the left to the first (upper cervical - not mid cervical) barrier
Translate left - not sidebend left
Elicit contraction of the segmental flexors (“look down toward your feet”) or sidebenders
(“look to the left)
Manually cue either under the chin or the left zygoma when providing the verbal
commands
Maintain both barriers during the contraction
Relax - take up slack – repeat

John Bourdillon FRCS, EA Day MD, M Bookhout MS, PT: Spinal Manipulation, p. 266, 1992
Occipital Distraction in Extension and Sidebending
Cues: Contacts and force application is similar to the occipital distraction in flexion
Position the patient at the barriers of occipital extension (not cervical extension) and left
translation - as he/she exhales
Maintain these barriers – apply the distraction mobilizations or manipulation

John Bourdillon FRCS, EA Day MD, M Bookhout MS, PT: Spinal Manipulation, p.268, 1992

Cervical Spine and Related Lower Extremity Radiating Pain
ICD-9-CM code: 724.4 cervical radiculitis
ICF codes: Activities and Participation Domain code: d4108 Changing a basic body
position, other specified - specified as: extending and
rotating the head and neck, such as in looking behind
oneself to the left or to the right
Body Structure codes: s76000 Cervical vertebral column
s7309 Structure of the upper extremity, other specified
Body Functions code: b28010 Pain in head and neck
b2803 Radiating pain in a dermatome

Shooting, narrow band of pain - usually below the elbow
Paresthesias
Numbness
Weakness
May adopt posture to relieve nerve tension
Symptoms reproduced with extension and sidebending toward the involved side
(extension quadrant or Spurling’s test)
Symptoms reproduced with upper limb nerve tension test
May have sensation deficits and strength deficits in the upper extremity
Cervical Extension, Sidebending and

Rotation to the Same Side
Performance Cues:
This cervical “Quadrant” narrows the inter vertebral foramen (as well as approximates
the cervical facets)
Assess relation between movement and symptom reproduction

Upper Limb Nerve Tension Test
Median Nerve Stretch Test
Performance Cues:
Determine baseline level of symptoms
Assess change in symptoms as each of the following components of the test are gradually
added - take up the slack only to the initial tissue resistance or report of
symptomatology:
1. Scapular depression
2. Humeral abduction (not past 90 degrees)
3. Humeral external rotation (not past 90 degrees)
4. Forearm supination
5. Wrist, thumb, and finger extension
6. Elbow extension
Sensation Tension
Performance Cues:
C5 - Lateral anticubital fossa
C6 - Anterior distal aspect of thumb
C7 - Anterior distal aspect of middle finger
C8 - Anterior distal aspect of little finger
T1 - Medial aspect of arm, just proximal to elbow
Assess light touch and/or sharp-dull, comparing to uninvolved side

C5 - Biceps Brachii MMT C6 - Extensor Carpi Radialis C7 – Triceps MMT
Longus and Brevis MMT
C8 - Flexor Digitorum Profundus MMT T1 - Abductor Digiti Minimi and First Dorsal
Interosseous MMT
Performance Cues:
Assess motor involvement by using manual muscle tests to determine strength deficits
Compare strength to uninvolved side and with norm for age, gender, and activity level
Manual muscle test norm is ability to move fully against gravity and take moderate-to-
maximal resistance without giving or fatiguing
Cervical Spine and Related Upper Extremity Radiating Pain

Description, Etiology, Stages, and Intervention Strategies
“Cervical Radiculopathy”
Description: Cervical radiculopathy is, by definition, a disease of the cervical spinal nerve root.
It is most commonly caused by a cervical disc herniation or other space occupying lesion such as
a osteophytic encroachment associated with spondylosis or a tumor. This encroachment from a
space occupying lesion can result in nerve root impingement, inflammation, or both. The chief
symptom is a narrow band of lancinating pain that radiates to the shoulder girdle and upper
extremity. The primary signs are unilateral paresthesias , sensory deficits, diminished muscle
stretch reflexes and motor deficits in the shoulder girdle and upper extremity.

Etiology: Cervical radiculopathy is usually of non-traumatic origin and occurs spontaneously in
the majority of cases. In younger adults the most common cause of this disorder is disc
herniation, whereas cervical spondylosis is a more frequent cause in older patients. Peak
incidence of cervical radiculopathy is in the fourth or fifth decade of life.

ICF Body Functions codes: b28010.3 SEVERE pain in head and neck; and b2803.3
SEVERE radiating pain in a dermatome
• Posture or positioning to relieve tension on the related nerve (e.g., cervical flexion or
sidebending, elevated scapula, arm supported or held with wrist resting on head)
• Positive Shoulder Abduction Test relieves symptions (i.e., the patient elevates arm
overhead and places hand on head to bring on a relief of symptoms)
• Decreased cervical rotation (cervical rotation < 60°)
• Positive Spurling’s Test (i.e., cervical extension/sidebending/rotation toward the
involved side with compression reproduces radicular symptoms)
• Positive Manual Traction Test (i.e., axial manual traction to cervical spine relieves
symptoms)
• Peripheralization or centralization of symptoms with repeated movements
• Positive Upper Limb Tension Test (i.e, tension or stretch of the involved nerve root
and its associated nerve reproduces the radicular symptoms)
• Positive neurological signs (i.e., diminished sensation to the skin served by the
involved nerve root and motor weakness of the muscles served by the involved nerve
root and diminished deep tendon reflexes associated with specific nerve roots)
ICF Body Functions codes: b28010.2 MODERATE pain in head and neck; and b2803.2
MODERATE radiating pain in a dermatome
• As above – the severity of the radicular signs may resolve as the inflammation around
the involved nerve root diminishes
• Now (when less acute) assess upper quarter postural alignment, muscle balance (i.e.,
muscle flexibility and strength deficits), and pertinent ergonomic factors contributing
to the patient’s symptoms/functional limitations
Settled Stage / Mild Condition: Physical Examinations Findings (Key Impairments)

ICF Body Functions codes: b28010.1 MILD pain in head and neck; and b2803.1 MILD
radiating pain in a dermatome
• Radicular symptoms are reproduced only with end-range sustained positions of the
cervical spine or sustained tension positions of the involved nerve root and it
associated upper extremity nerve

Clinical Examination for Cervical Radiculopathy (Wainer)
• If three of the four following tests are positive the probability of the condition
increases to 65%.
• If all four of the following tests are positive the probability of the condition increases
to 90%.
• If ULTTA is negative, the probability of the condition is 3%, essentially Cervical
Radiculopathy can be ruled out.
1. ULTTA (Upper Limb Tension Test A)
2. Involved cervical rotation less than 60°
Goals: Improve neurological status

Reduce radicular pain

Limit movements or activities that aggravates the symptoms. For example, use of
1) a soft cervical collar, or 2) slight cervical flexion, sidebending opposite of
radiculopathy and retraction positions and motions increase neural foraminal size
– may be used to reduce further forminal aggravation during the inflammatory
stage.
Nerve mobility execises in painfree ranges
• Manual Therapy
Manual cervical traction
Soft tissue mobilization to the myofascial restrictions in the areas of upper
extremity nerve entrapments associated the involved nerve root
• Neuromuscular Reeducation
Facilitate cervical positions that optimally open the involved foramin – typically
by promoting neutral positions of the thoracic cage, scapular, neck and head
positions during daily activities.
Sub Acute Stage / Moderate Condition:
Goal: Prevent recurrence

Settled Stage / Mild Condition:
Goal: Progress activity tolerance
Maximize muscle performance of the relevant trunk, scapulae, shoulder girdle and
neck muscles required to perform the desired occupational or recreational
activities
Add job/sport specific training
Intervention for High Performance/High Demand Functioning in Workers or Athletes:
Selected References
Abdulwahab SS, Sabbahi M., Neck retraction, cervical root decompression, and radicular pain. J
Ortho Sports Phys Ther. 2000; 30: 4-8
Davidson RI., Dunn EJ., Metzmaker JN. The shoulder abduction test in the diagnosis of radicular
pain in cervical extradural compressive monoradiculopathies. Spine. 6:441-6, 1981.
Farmer JC., Wisneski RJ. Cervical spine nerve root compression. An analysis of neuroforaminal
pressures with varying head and arm positions. Spine. 19:1850-5, 1994.
Humphreys SC., Hodges SD., Patwardhan A., Eck JC., Covington LA., Sartori M. The natural
history of the cervical foramen in symptomatic and asymptomatic individuals aged 20-60 years
as measured by magnetic resonance imaging. A descriptive approach. Spine. 23:2180-4, 1998.

Jordan A., Bendix T., Nielsen H., Hansen FR., Host D., Winkel A. Intensive training,
physiotherapy, or manipulation for patients with chronic neck pain. A prospective, single-
blinded, randomized clinical trial. Spine. 23:311-8, 1998.
Lentell G., Kruse M., Chock B., Wilson K., Iwamoto M., Martin R. Dimensions of the cervical
neural foramina in resting and retracted positions using magnetic resonance imaging. J Orthop
Sports Phys Ther. 32:380-90, 2002
Muhle C., Resnick D., Ahn JM., Sudmeyer M., Heller M. In vivo changes in the neuroforaminal
size at flexion-extension and axial rotation of the cervical spine in healthy persons examined
using kinematic magnetic resonance imaging. Spine. 26(13):E287-93, 2001
Persson, Liselott CG. et al. Long-lasting cervical radicular pain managed with surgery,
physiotherapy, or a cervical collar. Spine. 1997; 22:751-758
Radhakrishnan K., Litchy WJ., O'Fallon WM., Kurland LT. Epidemiology of cervical
radiculopathy. A population-based study from Rochester, Minnesota, 1976 through 1990. Brain.
117 ( Pt 2):325-35, 1994.
Saal S, Yurth E.F. Nonoperative management of herniated cervical intervertebral disc with
radiculopathy. Spine. 1996; 21:1877-1883
Van der Heijden GJ., Beurskens AJ., Koes BW., Assendelft WJ., De Vet HC., Bouter LM. The
efficacy of traction for back and neck pain: a systematic, blinded review of randomized clinical
trial methods. Phys Ther. 75(2):93-104, 1995.
Viikari-Juntura E, Porras M., Laasonen E.M. Validity of clinical tests in the diagnosis of root
compression in cervical disc disease. Spine. 1989; 14:253-257.
Wainner RS., Gill H. Diagnosis and nonoperative management of cervical radiculopathy. J

Orthop Sports Phys Ther. 2000;30:728-744.
Wainner RS., Fritz JM., Irrgang JJ., Boninger ML., Delitto A., Allison S. Reliability and
diagnostic accuracy of the clinical examination and patient self-report measures for cervical
radiculopathy. Spine. 28(1):52-62, 2003.
Wolff MW, Levine LA. Cervical radiculopathies: conservative approaches to management. Phys
Med Rehabil Clin N Am. 2000, 13:589-608

Cervical and Shoulder Examination
Algorithm #1
Suspect 1) Fracture or Loss of Connective Tissue

Integrity Due to Trauma or Disease, and/or 2) Yes Stabilization
Abnormal/Hypermobile Cervical Segmental Mobility Procedures
No
Consultation with Yes Screen for Potentially Serious If Negative Medical Clearance and
Appropriate Non-Musculoskeletal Negative Imaging
Healthcare Provider Pathology
If Negative
Cervical
Examination
Algorithm #2
Emmanuel Yung PT, MA, OCS Skulpan Asavasopon MPT, OCS Joe Godges DPT, MA, OCS KP So Cal Ortho PT Residency
Cervical Examination and Intervention
Algorithm #2
Cervical and Upper

Pain During Movement or Thoracic Single Plane Pain Does Not Limit Motion
Pain Limits Motion in Available Active Mobility in Available Ranges and/or
Ranges or Movement Produces Examination Pain at End of Range Does Not
Peripheral Symptoms Produce Peripheral Symptoms
If Positive for Upper

Motor Neuron Cervical Spine Side Produces
Consultation Bending, and/or Vertebrobasilar
Lesions Neurological Vertebro-
Insufficiency Exam
with Other Combined Side Basilar
Healthcare Status Bending/Rotation Insufficiency
Providers Examination Produces Peripheral Symptoms /Extension Signs
Over Pressures
Does Not Produce If Safe to Proceed

Peripheral Symptoms
Mobility Examination of
• Upper Quarter Neural Elements If Segmental Instability
Mobility Examination of:
If Negative
• Peripheral Nerve Entrapment Sites • Upper Thoracic and Cervical Spine

• Upper Quarter Neural Elements
If Symptoms
Unresolved If Positive If Negative
Pain Pain Resistance Resistance

Limited Limited Limited Limited
Nerve Cervical Nerve Cervical
Mobility Mobility Mobility Mobility
Nerve Entrapment Cervical Stabilization Mobilization of Upper Mobilization of

Reduction Procedures Procedures Quarter Neural Elements Cervical and Thoracic
Spinal Segments
If Symptoms Resolve to the Point Where Pain Does Not

Limit Motion in Available Range, Return to Single Plane To Algorithm #3
Active Mobility Examination Shoulder Examination
Shoulder Examination and Intervention Algorithm #3a
Active ROM Tests:

1) Elevation
2) 90/90 or Neutral External Rotation
3) Hand Behind Back
Passive ROM Tests:

1) Elevation with Over Pressure
2) Isolated Glenohumeral External Rotation\
3) Isolated Glenohumeral Internal Rotation
Passive Accessory Motion Tests:

1) Posterior Humeral Translation
2) Anterior Humeral Translation
3) Inferior Humeral Translation (sulcus sign)
4) Acromioclavicular Accessory Movements
Resisted Tests:
1) External Rotation
2) Abduction Active Compression
3) Flexion Test
Palpatory Examination of
Suspected Enthesopathy
To Algorithm #3b
• First Time Traumatic Algorithm #3b • Dislocation
• Night Pain
Dislocation • Over 40 Years of Age
• Weak External Rotators
• Age ≤25 Years Old • Shoulder Elevation <90 or • Over 65 Years of Age
degrees after 6 weeks
Medical/Surgical Suspect Medical/Surgical

Consultation in Glenohumeral Suspect Consultation in
Addition to PT Capsuloligamentous Addition to PT
Rotator
Intervention Labral Tear Intervention
Cuff Tear
Pain Limits Active and • Normal or Excessive Active and Passive • Pain with Active Motions • Limited Active and Passive
Passive Movements in Range of Motion • Pain with Passive Over Pressure Range of Motion
Mid Ranges • Painful and/or Excessive Humeral • Weak and/or Painful Resisted Tests • Limited Humeral Accessory
Accessory Motions
Motions
• Positive Active Compression Tests
Pain
continuum Resistance
Limited Impingement
Instability Limited
Shoulder
Shoulder
Mobility
Mobility
Physical Agents and Shoulder Strengthening Shoulder Shoulder Mobilization

Ergonomic Counseling Therapeutic Exercises Strengthening Procedures
Therapeutic Exercises
If Symptoms Resolve, and Pain No Consultation

Longer Limits Active and Passive Associated Upper Quarter
Impairment Examination with Other
Movements in Mid Ranges, Return to Healthcare
Start of Algorithm #3 Algorithm #4
Providers
If Symptoms Unresolved
Associated Upper Quarter Impairment Examination
Algorithm #4
Shoulder
Physical Shoulder
Stabilization
Agents and Shoulder Mobilization
Procedures and
Ergonomic Strengthening Procedures
Therapeutic
Instructions Exercises Therapeutic
Exercises
Nerve Mobilization of
Entrapment Mobilization of Cervical and
Upper Quarter Cervical
Reduction Thoracic Spinal
Neural Elements Stabilization
Procedures Segments
Procedures
Strength/Motor Control/Endurance Deficits

Deep Neck Flexors Lower Trapezius Middle Trapezius Serratus Anterior
Flexibility Deficits
Levator Scapulae Pectoralis Major Pectoralis Minor
Upper Trapezius Latissimus Dorsi Subscapularis
Suboccipital Myofascia Teres Major Sternocleidomastoid
Postural Deficits
Excessive Capital Extension Protracted Scapulae Excessive Thoracic Kyphosis
Selected References
Aker PD, Gross AR, Goldsmith CH, Peloso P. Conservative management of mechanical neck pain: systematic overview and meta-analysis. BMJ.
1996;313:1291-6.
Antonaci F, Ghirmai S, Bono G, Sandrini G, Nappi G. Cervicogenic headache: evaluation of the original diagnostic criteria. Cephalalgia. 2001;21:573-
83.
Aprill C, Dwyer A, Bogduk N. Cervical zygapophyseal joint pain patterns. II: a clinical evaluation. Spine. 1990;15:458-61.
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SUMMARY OF CERVICAL SPINE DIAGNOSTIC CRITERIA AND PT MANAGEMENT STRATEGIES
DISORDER HISTORY PHYSICAL EXAM PT MANAGEMENT

“Cervical Facet Unilateral neck pain – commonly SR with: End range rotation left or Segmental STM and C/R
Syndrome” with referral (from occiput to right Joint mob/manip
scapula) Palpation of involved facet Ther Ex’s
723.1 onov* = 4 or less Strain, unguarded or awkward Restricted accessory movement of
mnov** = 8
movement or position the involved facet
“Cervicogenic Unilateral neck pain with referral to Observable postural asymmetry of Postural re-education
Headache” occipital, temporal, parietal, the head on neck (sidebent or Ergonomic Instructions
frontal or orbital areas extended) ST and joint mob/manip (w/ the head
723.2 onov = 4 or less HA precipitated/aggravated by neck HA reproduced with provocation of and neck in neutral) to the
mnov = 12
movements or sustained positions the involved segmental ST/Joints restricted segmental motions
Noncontinuous HA (usually < 1 O/C1, C1/C2, or C2/C3 restricted Address related upper ¼ muscle
episode/day, < 2 episodes/week) accessory motions with associated imbalances and joint impairments
myofascial trigger points Upper cervical Ther Ex’s
“Cervical Lancinating pain to UE SR with: Ext/SB to same side Patient education (Positions of
Radiculopathy” Paresthesias ULTT reduced nerve entrapment/tension)
Numbness May have neuro signs (UE sensory, Manual or mechanical traction
724.4 onov = 8 or less Weakness motor, and reflex deficits) Reduce entrapment (STM, JM,
mnov = 20
Nerve mob, ergonomic cuing,
postural cuing, Ther Ex - where
indicated to address the patient’s
impairments)
Cervical Ligament Trauma Pain with motion – worsens at end Stabilization (C-collar, Ther Ex,
Sprain Protective muscle spasm range positioning, ergonomic cuing)
SR with palpation or provocation (via Rx mobility impairments of adjacent
847.0 onov = 8 or less central PA’s of the involved segments or regions
mnov = 20 ligament or segment) Later, add strength and endurance
May have laxity with ligamentous training if applicable
stress tests
onov = optimal number of visits

mnov = maximal number of visits
SR = Symptom Reproduction
Joe Godges, DPT, MA, OCS KP So Cal Ortho PT Residency

1
Mid-Cervical Spine Fusion
Anatomical Considerations: The cervical spine consists of several joints. It is an area where
stability has been sacrificed for mobility, making the cervical spine particularly vulnerable to
injury. The superior apophyseal (aka facet) joints of each segment face upward, backward, and
medially. The inferior facets face downward, forward, and laterally. This facet orientation
facilitates flexion and extension, but it prevents isolated rotation or side flexion. Thus, rotation
and sidebending occur together (i.e., coupled) in the mid-cervical spine. These joints move
primarily by gliding and are classified as synovial (diarthrodial) joints. The greatest flexion-
extension of the facet joints occurs at C5 and C6; however, there is almost as much movement at
C4-C5 and C6-C7. Because of this mobility, degeneration is most likely to be seen at these
levels. The neutral or resting position of the cervical spine is slightly extended. The closed
packed position of the facet joints is complete extension. The intervertebral discs make up
approximately 25% of the height of the cervical spine.
Pathogenesis: The cervical spine can be structurally compromised by differing mechanisms,

such as instability resulting from trauma or the degenerative processes associated with aging.
The degenerative process involving the cervical spine is also known as cervical spondylosis.
Disc degeneration and osteophyte formation are present on radiological studies in a majority of
the population by the age of 55, yet many people never develop symptoms. Cervical disc
degeneration occurs most commonly at the C5-C6 and the C6-C7 levels. The decreased water
content of the disc may result in a narrowing of the disc space and loss of disc height, which
increases the shearing motion at the affected disc space and further contributes to the
degenerative process. Many people develop osteophytes along the spine as a result of the
degenerative process. These osteophytes may compress or irritate the cervical nerve root at the
affected level or levels. Fissures may develop in the annulus, which can allow portions of the
nucleus to protrude through the annulus. Disc herniations may irritate or compress the spinal
nerve roots exiting the spinal cord, causing pain or numbness along the distribution of the nerve.
The degenerative process can also cause narrowing of the spinal canal (spinal stenosis),
compression of the spinal cord, or compression of the vessels supplying the spinal cord, resulting
in cervical myelopathy. Cervical myelopathy may produce numbness and weakness in the upper
extremities (lower motor neuron signs) and can also cause long track (upper motor neuron) signs
affecting lower extremity function. Infections or tumors of the vertebral column can greatly
exaggerate the deleterious neurological changes and subsequent loss of function.
Epidemiology: Research into the epidemiology of cervical disc disease indicates that men are
affected more often than women by a small margin. Most people with symptomatic herniated
cervical discs are in their 40’s and 50’s. Cigarette smoking also is associated with increased
incidence of cervical disc disease. The most common symptoms seen in patients for treatment of
cervical degenerative disc disease are neck pain, occipital headaches, pain and numbness
radiating to one or both shoulders, the scapular region, or arms and hands.
Many patients have radicular symptoms, which are pain, paresthesias, motor and sensory deficits
due to disorders of the nerve roots, typically due to compression at the cervical lateral forminal
canal. Radicular pain can be aggravated or relieved by the patient’s neck and head position.
Neck flexion can relieve symptoms in some patients, and lateral flexion or rotating the head
Loma Linda University and University of Pacific Doctorate in Physical Therapy Programs Joe Godges DPT, MA, OCS
2
toward the affected arm may increase pain and numbness.
Diagnosis: A combination of plain radiographs and magnetic resonance imaging (MRI) with or
without computed topography (CT) myelograms often is used in the diagnosis of patients
presenting with symptoms of degenerative cervical disc disease. Plain x-ray films can be used to
determine whether cervical entophytes are present and whether a loss of disc height is present in
the cervical spine. The disc space and cervical nerve roots can be examined by MRI scan to
identify disc herniation. Compression of the spinal cord or nerve roots can be identified with CT
myelograms.
Non-operative versus Operative Management: Conservative treatment for patients with

symptomatic degenerative disc disease includes rest, pain medication, non-steroidal anti-
inflammatory medications, physical therapy including: intermittent cervical traction, positioning,
ice/heat, ultrasound/phonophoresis, electrical stimulation, soft tissue mobilization, joint
mobilization, nerve mobilization, exercises for flexibility, strength, coordination and overall
fitness; posture and ergonomics. Many patients benefit from conservative treatment and
experience a resolution of symptoms. Patients who continue to have pain, numbness, or
weakness, despite conservative therapy for approximately 6 to12 months, may be candidates for
surgical intervention. However, host factors that have a negative impact on obtaining a fusion
play a role in determining whether a patient is a candidate for surgery. These factors include
cigarette smoking (nicotine is a bone toxin), osteoporosis, chronic steroid use, and malnutrition.
Surgical Procedures:
Anterior Cervical Discectomy and Fusion (ACDF): The patient is placed supine on the table.
Under general anesthesia, the neck is draped in sterile manner. The correct level is identified
under x-ray control. A transverse incision of approximately 1.8 cm is made at the desired level.
After the incision the sternocleidomastoid and the strap muscles are identified. The anterior
surface of the cervical spine is exposed. The longus colli muscles are reflected laterally at the
C4-5 level and the level is once again identified under x-ray control. A self-retaining Cloward
retractor is placed and the disk space is identified.
Anterior Cervical Diskectomy: With the help of pituitary forceps and curettes, the disk is
removed as posteriorly as possible. The posterior longitudinal ligament is visualized. Further
disc is removed from the foramina on both sides. The foramen is probed with a nerve hook
and further decompression is carried out with the help of Kerrison rongeur.
Anterior Cervical Fusion: The end plates are lightly burred with a high-speed burr to expose
the bleeding subchondral bone. Sizing of the disc is performed. Appropriate allograft is
taken and inserted in the disc space under tension. The graft fixation is checked for fit.
Cervical Plating: The appropriate sized cervical plate is selected. It is applied to the anterior
surfaces of the involved vertebra. Position is identified under x-ray control. This is fixed to
the vertebrae with the help of four 14mm screws. The fixation is checked. The wound is
irrigated and deeper tissues are closed with sutures and then, the skin is closed with sutures.
Marcaine is injected into the edges of the skin. A sterile dressing is applied and a cervical
3
collar is given. The patient is awakened and transferred to the recovery room.
Discectomy and Posterior Microendoscopic Fusion (Posterior Approach). This approach is

commonly usually used with cervical spine fractures. The patient is placed in the semi-sitting
position. A skin incision of 1.8 cm is made 1.5 cm laterally from the midline. Under
radioscopy, the progressive dialators are inserted through the paravertebral muscles up to the
cervical laminae. After the tubular retractor is inserted, the optic fiber and camera are adjusted.
The remaining part of this procedure is very similar as the anterior approach. The semi-sitting
position prevents the excess of venous epidural bleeding.
The ACDF procedure is associated with a low overall rate of complication. Retrospective
studies of patients after ACDF indicate that 80-90% of patients have good to excellent outcomes,
including relief of symptoms and successful fusion. However, there are many surgical
complications. These include hoarseness of voice (usually temporary but can be permanent);
temporary dysphasia; esophageal, tracheal, or vertebral artery injury; wound infection; injury to
the spinal cord or nerve root; dura mater tears with associated cerebrospinal fluid leaks;
pseudoarthrosis caused by nonunion of fusion; graft extrusion; and screw loosening.
Preoperative Rehabilitation: Preoperative treatment is to establish a conditioning program for

surgery. Included in this program is keeping the affected joint from excessive mechanical forces
and instructing the patient in proper postural body mechanics and exercise program.
Medications such as non-steroidal anti-inflammatory drugs, acetaminophen, muscle relaxants,
and possible narcotics are prescribed for pain control. Spinal injections can be used for both
treatment and diagnostic purposes. Injections usually use a mixture of an anesthetic and some
type of cortisone preparation. The anesthetic numbs the area of the injection site. If the
injection takes away the pain immediately, suggests that the injection site is indeed the source of
the pain. The cortisone decreases inflammation and can reduce the pain from an inflamed nerve
or joint for a prolonged period of time. Types of injections include: epidural steroid in injection
(ESI), selective nerve root injection, facet joint injections, and trigger point injections.
POSTOPERATIVE REHABILITATION
Note: The following rehabilitation progression is a combination of guidelines provided by

Bhatnagar et al. Refer to this publication to obtain further details.
Phase I: 1-10 days post-op
Goals: Protect repair

Control pain
Independence in activities of daily living
Minimize deconditioning
4
Intervention:
• Patient may be instructed and fitted for home bone stimulation unit
• Instruct in proper positioning and controlled movement
• Other considerations:
The wounds are usually sore for about 5 days. The hip will always hurt more than the
cervical spine if this was the donor site.
The patient is allowed to shower after about 2-3 days post-op. No bathing or swimming.
It is common to have initial problems with swallowing.
Complaints of a hoarse voice may be present - this should improve over the next 3
month.
Phase II: 2-12 weeks post-op.
Goals: Continue to protect fusion

Continue to control pain
Increase active and passive range of movement
Normalize movement patterns
Increase endurance, aerobic conditioning.
Intervention:
• Ergonomic instruction - The patient is advised to not lift more than 2 pounds and avoid
sudden movements of the neck for the initial 6 weeks.
• Progressive ambulation for the first 6 weeks is the safest and easiest exercise to develop
stamina. It is suggested that 2-4 shorter distance walks are more beneficial rather than
once for long distance.
• After 6 weeks patient is advanced to other low-impact aerobic activities: Stairmaster,
upper body ergo meter, stationary bicycle and swimming.
• Other Considerations: For the initial 6 weeks the patient is instructed to NOT vacuum,
sweep, garden, make the bed, perform home repairs, or carry heavy items like children,
wet laundry, or firewood. Some patients will be allowed to drive after about 6 weeks.
Some patients might return to work after approximately 4-6 weeks depending on
occupation, recovery and complications after surgery. All patients are instructed to
refrain from heavy lifting (>22 pounds) for the first year.
Phase III: usually after 3 month.
• Progress therapeutic exercise programs to include passive extremity stretching

strengthening with a full progressive resistive exercise program using isotonic, isometric,
and isokinetic exercises.
5
• Other considerations: Minimal control is provided with soft collars but they provide
warmth and proprioceptive feedback and are inexpensive and convenient.
Phase IV: Autonomous stage: (On-going)
Goals: Return to high level/high intensity activities for prolonged periods of time.
Intervention:
• Work hardening/conditioning
• Dynamic co-ordination and balance activities
These post-surgical exercises are very similar activities used to prevent surgery and have
been shown to be an effective treatment with long-term reductions in pain and functional
disability in subjects diagnosed with cervical segment instability and chronic cervical
pain. For operative or for non-operative patients the approach is the same, it is based on a
motor learning model where faulty movement patterns are identified and components of
movement are isolated so they can be retrained into functional tasks.
Selected References:
Bhatnagar M, et al. Spinal Fusion and Rehabilitation Aftercare. www.simmonsortho.com. 2004.
Brown C., Eismont F. Complications in spinal fusion. Orthopedic Clinics of North America.
1998;29: 679-697.
Cherry, C. Anterior cervical discectomy and fusion for cervical disc disease. AORN Journal.
www.looksmart.com. 2003.
Melbourne Neurosurgery. Anterior Cervical Discectomy and Fusion post operative information.
www.neurosurgery.com.au. 1-15-2005.
Omura K., et al. Evaluation of posterior long fusion versus conservative treatment for
progressive rheumatoid cervical spine. Spine. 2002;27;1336-1345.
Sasso, R. M.D. Screws, Cages or Both? www.spineuniverse.com 7-31-2003.
Pimenta LMH. Cervical Spine Approaches by Metrix. www.spineuniverse.com. 12-12-2003.
Vaccaro A., et al. Cervical trauma: rationale for selecting the appropriate fusion technique.
Orthopedic Clinics of North America. 1998;29:745-754.
1
Upper Cervical Spine Fusion
Surgical Indications and Considerations
Anatomical Considerations: The occiput-C1 articulations primarily allow for flexion and
extension movements and the C1-C2 articulations primarily allow for rotation. Fifty percent of
cervical spine rotation occurs at the C1-C2 joint complex.
Pathogenesis: Upper cervical instability can occur from intrinsic factors, such as rheumatoid
arthritis, or extrinsic factors, such as trauma. Rheumatiod arthritis most commonly affects the
cervical region as compared to the thoracic and lumbar regions. In the affected cervical spine,
articular cartilage is destroyed and the inflamed soft tissue enlarges to involve the neighboring
structures. Ligaments undergo “distention, attenuation,” and rupture. Bone erosion occurs with
osteoporosis, and cyst formation develops which can lead to changes in vertebral alignment in
the upper and subaxial cervical spine. Rheumatoid arthritis can also lead to lesions such as
atlantoaxial subluxation, atlantoaxial impaction, and subaxial subluxation. These lesions can
cause compression of the spinal cord and can lead to generalized debility that can “culminate”
into tetraparesis or death. Instability of the atlantoaxial joint can also occur congenitally, such as
in the case of Down syndrome.
Extrinsic factors such as hyperextension injuries from motor vehicle accidents or falls can lead to
instabilities of the upper cervical segments. Hangman’s fractures or C2 traumatic
spondylolisthesis involves a fracture to the pars interarticularis of the dorsal element. Other
pathological conditions that can warrant a spinal fusion are atlanto-occipital
subluxation/dislocation, atlas fractures, odontoid fractures, and occipital condyle injuries
secondary to an avulsion of an ipsilateral alar ligament and supporting soft tissue structures as a
result of excessive “shear, lateral bending, and rotary forces.”
Epidemiology: As mentioned above, rheumatoid arthritis is a major contributing factor related to

cervical lesions. Cervical spine subluxations are observed in 43 to 86% of patients, and occur
more in males, despite a greater propensity for rheumatoid arthritis in women. According to a
study, atlantoaxial subluxation and basilar “invagination” occur in 39% and 11% of patients with
rheumatoid arthritis. Clinically, these patients present with severe neck pain, as well as
myelopathy from craniocervical instability and spinal cord compression. If left untreated, the
condition can cause neurological decline, patients can become bedridden, and the chances of
surviving beyond seven years is unlikely.
Extrinsic biomechanical stress to the cervical spine is another factor which can contribute to
cervical lesions. Upper cervical spine injuries resulting from trauma includes: 1)occipital
condyle injuries resulting from an avulsion of the ipsilateral alar ligament from excessive shear,
lateral bending, and rotatory forces, 2) atlanto-occipital subluxation/dislocation (survivals of this
injury are rare) these injuries can cause a severe amount of instability and can be associated with
cranial nerve and spinal cord involvement, 3) atlas fractures which can lead to C1-C2 instability
due to “incompetency” of the transverse ligament and surrounding capsular structures, and 4)
odontoid fractures, which account for 5-15% of cervical spine fractures.
2
Diagnosis:
• For upper cervical disc herniation clinical presentation may include numbness of the
hands and arms, loss of fine motor control, dysesthesia or hypesthesia to pinprick
stimulation, proprioception loss, ascending tingling and numbness in fingers, paresthesia
over arms, neck pain, and loss of balance
• Mechanism of injury includes hyperextension or hyperflexion injuries involved with
motor vehicle accidents or a fall from a height
• Clinical assessment include utilizing the alar ligament testing, Sharp-Purser testing, VBI
insufficiency tests, and neurological status examination
• MRI and CT scans are helpful in demonstrating the presence, location, and severity of
any fractures, subluxations, or cord compression
• Radiographs are also used to rule out bone pathology such as collapse of the vertebral
bodies and osteophyte formation.
Nonoperative Versus Operative Management: Fusion of the upper cervical spine is usually
recommended for patients who are unsuccessful with conservative interventions, such as
ergonomic cuing, postural education, cervical stabilization/strengthening exercise and manual
therapy for mobilization of soft tissue and joint mobility deficits in the upper and mid cervical
spine segments.
The severity of the cervical lesion shown on imaging studies (MRI, CT scan and X-rays) as well
as the patient’s clinical presentation will determine if surgery for spinal fusion is indicated.
Radiographic findings such as 1) osteophyte formation into the spinal canal, 2) spinal cord
compression, and 3) odontoid and/or atlas bony involvement are all indications for surgical
stabilization. Surgical intervention does not guarantee that the existing problem will be cured.
There is always the possibility of post surgical complications. Early postoperative complications
(up to 1 month postoperatively) include infection, neurologic injury (delayed paresis), graft
extrusion (anteriorly and posteriorly), instrumentation loosening and failure. Late postoperative
complication can involve the adjacent vertebra segments because the fusion will change the
biomechanics of the cervical spine by placing increased stress on the non-fused joints, thus
increasing the risk of creating an instability in the segments adjacent to the surgically fused
segments. Higher complication rates associated with preoperative and intraoperative risk factors
include:
• Obesity
• Smoking
• Diabetes
• Osteoporosis
• Pulmonary conditions
• Malnutrition
• Cerebral palsy
• Myelodysplasia
• Longer surgical procedures
• Increased operating room traffic
• Failure to use antibiotics
3
Surgical Procedures:
Anterior Cervical Spinal Fusion: The procedure provides wide, bilateral exposure, it decreases
the incident of contamination of the oral and pharyngeal cavities, and it gives the surgeon access
to segments below C4. The patient is positioned supine with the head slightly extended and
rotated 30 degrees away from the surgical side. The surgeon makes an incision 2 cm below and
parallel to the mandible. A vertical incision of the platysma is made and is transected
horizontally. The submandibular gland is elevated, and the facial artery and vein are dissected
free. The digastric, hypoglossal, pharyngeal constrictor, longus colli, longus capitus muscles
along with the hypoglossal and superior laryngeal nerves and the ventral vertebral and carotid
arteries are carefully dissected and retracted to expose the anterior tubercle of C1, C2 and C3 so
they can be palpated. An allograft or autograft can be used depending on the patient
requirement. The grafts can be bone used from the humerus or the ilium. A plate is selected and
is measured to insure the distance from the top of the graft to the body of C3 caudally. Four
bicarbonate screws are used to secure the plate onto C1 and C3. Radiographic images are used
to help guide the pins and screw placements.
Posterior Cervical Spinal Fusion: The patient is positioned in prone. If the neck is stable, the
patient’s head is flexed forward to no further than a “finger-width” from the sternum. If not
stable, the procedure will be completed with the patient in the neutral position in traction or halo
immobilization. A posterior midline incision is made from the external occipital protuberance
caudally to allow sufficient exposure as far as C3 level. The dissection is kept midline and
“subperiosteally” to expose the spinous processes and laminae of C2 and C3 as far lateral as the
facet joints. Uncovering of the posterior arch of the atlas is performed with care. The occiput is
exposed if it is included in the fusion, and hemostasis is achieved by electrocautery. For C1-C2
fixation using the Magerl’s transartcular screw placement technique, long screws are placed
from the posterior aspect of C2 facet laminar junction to the C1 lateral mass by drilling.
Titanium lag screw of the desired length is used with its lagged part only in the C1 portion to
provide “compression fixation.” Radiographic images are used to help guide screw placements.
Damage to the vertebral artery can result. If damage to vertebral artery occurs with the
placement of the first screw, placement of the second screw is avoided. Lateral mass fixation at
C2-C3 level can also be achieved posteriorly. With this procedure, a titanium plate is positioned
over the facet joints and screws of 14 to 18 mm in length are inserted through the lateral mass of
C3 and into the pedicle of C2. This procedure is useful with facet dislocation type injuries and
instability at the level of the laminectomy.
Preoperative Rehabilitation: Since pathology due to rheumatoid arthritis involving the cervical
spine is linked with severe peripheral joint involvement, an attempt at slowing the “progression”
early by medical intervention is promoted. Monitoring the spine continuously with radiographic
as well as neurological examination is an important aspect of non-operative management. Non-
operative treatments include: cervical collars (may help decrease local discomfort), soft tissue
mobilization, strengthening/stabilization exercises, transcutaneous electrical nerve stimulation,
and anti-inflammatory medications.
4
POSTOPERATIVE REHABILITATION
Phase I: Hospital setting: 1-7 days post operation.
Goals: Control pain and swelling

Protect fusion
Intervention:
• Immobilization with rigid collar brace for 4-8 weeks
• Anti-inflammatory and pain medication
Phase II: After discharge: Post-op 4-8 weeks
Goals: Control pain

Protect fusion
Increase endurance
Movement into painfree range
Intervention:
• Rigid collar brace if indicated by physician
• Anti-inflammatory and pain medication
• Gentle AROM exercises into painfree ranges
• Strengthening exercises to tolerance – especially focus on endurance training of cervical
neck flexors
• Patient education of proper postural mechanics with functional activities
Part III: Outpatient physical therapy reconditioning program-3 phases
Phase I: Cognitive stage: 4-8 weeks
Goals: Protect the fusion

Control pain and inflammation
Maintain upright posture and neutral spine with functional activities
Increase soft tissue mobility of the cervical and scapular muscles
Intervention:
• Ice, hot packs, electrical stimulation, and soft tissue mobilization
• Postural re-education to maintain upright posture and neutral spine
• Passive and active stretches to the neck and shoulder complex
• Static cervical and dynamic scapular stabilization program
5
Phase II: Motor Learning: 8 weeks to 4 months
Goals: Progress cervical and scapular dynamic stabilization

Progress with endurance and upper extremity program
Intervention:
• Scapular and extremity strengthening while maintaining neutral spine
• Upper extremity endurance program (e.g., UBE, elliptical rider)
• Functional training simulating functional activities
Phase III: Autonomous stage: (on-going)
Goals: Return to unrestricted activity
Intervention:
• Work hardening and conditioning
Note: Most surgeons allow their patients to return to normal unrestricted activity and do not
recommend physical therapy after postoperative intervention.
Selected References
Benzel E. Upper cervical and occipitocervical arthrodesis. Spine Surgery: Techniques,

complications avoidance, and management. Philadelphia, Elsevier, 2005.
Brown C., Eismont F. Complications in spinal fusion. Orthopedic Clinics of North America.
1998;29: 679-697.
Chen T. The clinical presentation of uppermost cervical disc protrusion. Spine. 2000; 25:439-
442.
Craig E. Rheumatoid arthritis of the spine. Cervical spine trauma: upper and lower cervical spine
injury. Clinical Orthopaedics. New York, Lippincott Williams & Wilkins, 1999.
Harm J., Melcher R. Posterior C1-C2 fusion with polyaxial screw and rod fixation. Spine.
2001; 26:2467-2471.
Leamer, T. Lumber spine fusion. University of Pacific, Power point presentation. 2004
Matsunaga S., et al. Prognosis with upper cervical lesions caused by rheumatoid arthritis. Spine.
2003; 28:1581-1587.
6
Omura K., et al. Evaluation of posterior long fusion versus conservative treatment for
progressive rheumatoid cervical spine. Spine. 2002;27;1336-1345.
Sandhu F., et al. Occipitalcervical fusion for rheumatoid arthritis using the inside-outside
stabilization technique. Spine. 2003; 28:414-419.
Tan M., et al. Morphometric evaluation of screw fixation in atlas via posterior arch and lateral
mass. Spine. 2003; 28:883-895.
Vaccaro A., et al. Cervical trauma: rationale for selecting the appropriate fusion technique.
Orthopedic Clinics of North America. 1998;29:745-754.
Vender J., et al. Fusion and instrumentation at C1-3 via high anterior cervical approach. J
Neurosurg. 2000;92:24-29.
1
Thoracic Outlet Release
Surgical Indications and Considerations
AnatomicalConsiderations: There are three potential spaces for compression or entrapment

through the thoracic outlet. The first is the interscalene triangle located within the posterior
triangle of the neck. Within this triangle, the subclavian artery and brachial plexus lie. The
sublcavian vein usually lies anterior to the anterior scalene, outside the triangle. Therefore,
compression usually produces neurological and/or arterial symptoms. The second potential
space is the costoclavicular interval, which is between the clavicle and first rib. The final
potential space is the axillary interval. This area is made up of the deltopectoral fascia, the
pectoralis minor, and the coracoid all of which can put pressure on the neurovascular bundle
composing the thoracic outlet.
Pathogenesis: The etiology of TOS symptoms can be vascular (venous or arterial), neurologic,
autonomic, or a combination of the three. Compression usually creates symptomatology in the
medial cord distribution (radial three digits and volar aspect of the forearm). Late neurological
symptoms may include pain and/or sensory changes and paresthesias distributed over the face,
posterior and lateral neck, anterior shoulder, and posterior/lateral aspect of the humerus. Venous
symptoms could include distal edema (especially after activity) and pain (described as a dull
ache and non-specific) in same peripheral distributions. There are two different kinds of thoracic
outlet, entrapment vs compressive and distinguishing between them is important. A patient with
compressive TOS usually has poor posture and describes and insidious onset with no history of
any trauma. The subclavian artery and brachial plexus may be subjected to mechanical
compressions at one of the potential sites if a there is a presence of a cervical rib, abnormal first
rib, transverse enlargement of C7, hypertrophy of the surrounding muscles, abnormal
costocoracoid ligament, abnormalities of the clavicle, regional enlargements. In comparison, a
patient with entrapment TOS usually has co-morbidity(ies) including cervical and/or shoulder
trauma or may be related to long standing repetitive stress activities. This patient’s symptoms
are usually delayed in relationship to the initial trauma and the pain is constant. Treatment to
patients with entrapment TOS usually provokes their symptoms.
Epidemiology: The incidence of TOS is between 50%-80% in women usually manifesting in

their forties. Because of the two kinds of TOS, poor posture, people who adopt poor body
mechanics especially sitting at a desk, and/or trauma to surrounding areas can predispose a
person to TOS. There also seems to be a high correlation between worker compensated patients
and outcomes of TOS treatment.
Diagnosis:
• Neurovascular compression tests: Adson test (positive in 60% of TOS patients), Wright
test (positive in 18%), McGowan-Velinsky test (positive in 38%), elevated arm stress test
(EAST – positive in 68%)
• Positive for TOS on electromyography
• Positive Doppler fluximetry (with dynamic tests post-operatively)
2
Indications for Surgery in Neurogenic TOS:

1. Confirmed diagnosis based on history and physical examination. Does not require
objective findings, such as neuroelectric studies, arterial vascular studies, or angiograms.
2. All associated or differential diagnoses have been evaluated and treated.
3. Appropriate physical therapy has been tried for at least 3-6 months and has failed.
4. The patient is experiencing some degree of disability at work, recreation, sleep or
activities of daily living.
Nonoperative vs. Operative Management: Surgery has been shown to be successful when
conservative treatment of TOS has failed or when patients have too severe of symptoms to
tolerate conservative treatment. TOS release should be performed only on people with non-
disputed TOS (neurogenic, arterial, or venous forms), however objective diagnosed cases are
rare. Therefore, most surgeries are done on people with disputed TOS. The most favorable
results of treating TOS have been shown through conservative management. However, a study
by Landry, GJ. et al (2001) stated that follow up data of 70 patients indicated that there were no
significant difference between the patients that had surgery and the patients that were treated
with non operative management. Another study by Toso, C et at (1999) stated that follow up
data of 28 patients would chose to have TOS surgery again if symptoms were to reappear and 13
said to have had a poor outcome. However, this article also admitted that conservative treatment
should always be tried first because most cases or TOS are due to muscle imbalance and poor
posture. Most authors agree that strengthening and stretching exercises should be administered
and surgery can be proposed when symptoms are too severe to be treated conservatively or after
6-12 months of unsuccessful conservative management.
Surgical Procedure: There is no surgical procedure proven to be better than any other. These
techniques include scalenotomy, scalenectomy, neurolysis, claviculectomy, and pectoralis minor
release. Some researchers state that if a cervical rib is present, surgeons can either resect it or
resect the first rib. If the surgeon chooses to resect the cervical rib, they can choose a
supraclavicular approach. If they choose to remove the first rib, they can choose a transaxillary
or transthoracic approach. If there a cervical rib is absent, then any of the three approaches
(supraclavicular, transaxillary, and transthoracic) are available. Neurolysis, another surgical
option, is considered easy to perform over C5, C6, and C7 nerves. C8 and T1 nerves are often
covered by various tissues including the scalene minimus muscle in 25% of people, which must
be removed. The scalenetomy procedure begins by retracting the C5 nerve medially and
identifying the long thoracic nerve (LTN), which arises from C5, C6, and C7 nerve. Once this
nerve is identified any or all of the three scalene muscles can be excised. The middle scalene is
the most common scalene excised. Once a scalenectomy and neurolysis are complete, the
operation can continue through the same incision with a first rib resection. Research, however,
as shown that success rates for scalenectomies with and without rib resections is 70% indicating
that there may not be need for a rib resection if scalenectomie(s) have occurred. Long-term
results indicate that complete scalenectomies (all three scalene muscles) did not have a better
success rate than subtotal or partial scalenectomies.
3
Preoperative Rehabilitation: Preoperative rehab tends to be heavily performed in hopes of

avoiding any form of surgery since most TOS can be corrected. Therefore, a preoperative
protocol is intensive and individualized.
Stage one – The goal in this stage is to decrease and control the patient’s symptoms. It is
imperative in this stage that the patient and therapist identify activities, positions, and treatments
that exacerbate and relieve the patient’s symptoms.
Stage two – This stage is initiated once control and comfort has been achieved. In this stage
tissues directly related to the TOS component can be addressed. This includes treating these
tissues that are creating structural limitations of motion or compression. During this stage,
treatment may exacerbate the patient’s symptoms, however, it should not last beyond the
treatment session. This stage introduces techniques such as soft tissue mobilization. These
manual techniques are to improve flexibility of involved tissues, restore normal resting lengths
of musculotendonous units, and assist in restoring normal posture. This protocol includes joint
mobilization of the acromioclavicular, sternoclavicular, and scapulothoracic joints, first rib, and
cervical spine. In addition, deep massage and stretching of the pectoralis group and stretching of
the scalene muscles should be performed. This is thought to potentially increase the size of the
space and minimize compression of neurovascular structures. In addition, this stage should
introduce postural awareness and correction as well as brachial plexus gliding and peripheral
nerve mobilization to decrease neural tension.
Stage three – This stage is when treatment gets intense. It involves all treatment techniques from
stage two but now introduces conditioning and strengthening of the muscles necessary to
maintain the postural correction.
The home exercise program proposed by Walsh, M. (1994) includes scalene stretching, cervical
protraction and retraction, diaphragmatic exercises, pectoralis stretching, and shoulder-circle
exercises. Scalene stretching involves the anterior and medial scalene which is done preferable in
supine to maximize cervical muscles relaxation to maximally benefit from the stretch. Cervical
retraction is to assist with decreasing the patient’s forward head and rounded shoulder posture.
For diaphragmatic exercises the patient rests in supine, arms at his/her side, takes an
inspirational breath and exhales maximally using abdominal muscles to stabilize the inferior
portion of the rib cage. Pecoralis stretching is obtained many ways. Many choose to place
forearm against a doorway and stretch the pectoralis muscle as the patient steps through the
doorway. The same stretch can be achieved by placing both hands on opposite walls of a corner
while the patient leans into the corner. Shoulder-circle exercises are performed with the patient
sitting, arms at his/her lap, and then forms large shoulder circles forward and backward to
strengthen the scapulothoracic and involved structures in the patient’s TOS. Additional
exercises may be given as needed.
4
Post operative Rehabilitation: This post-operative rehabilitation protocol is for patients who
have undergone scalenectomy and neurolysis. If the first rib has been excised than slight
modifications may need to be made. Initially post operative rehab closely resembles pre
operative with emphasis on wound care, edema control and scar management while
incorporating range of motion (ROM) exercises and nerve gliding techniques.
Early Care: Patients are seen in therapy day one after leaving the hospital. The first area of
focus is on wound care and the patient may have a drain in the wound covered by Tegaderm.
Patients are instructed to keep track of the amount of drainage and when there is less than 10 ml
per 8 hours of 25 ml per 24 hours, the drain is removed. The drain site continues to be covered
to further reduce the chance of infection. If the wound continues to drain a bandage is applied
and the patient is instructed to keep sutures clean and dry. The patient is, however, allowed to
shower and swim once drain sites are closed and wound has not drained for a few days. A
pressure bandage should be applied to decrease edema and should be worn full time for the first
7-10 days post op, however can be removed temporarily if it interferes with cervical range of
motion. Sutures are removed 7-10 days post operatively and a scar pad can be worn at night.
The physical therapist can assist by educating the patient in edema control techniques as part of
their home exercise program (HEP). Retrograde massage for the involved upper extremity can
be performed. An arm sling should be worn for the first 2 weeks when walking around or riding
in a car, but should be encouraged to keep their arm out of the sling and elevated on pillows
when sitting or sleeping. Patients should sleep on their uninvolved side with a pillow supporting
the involved side. Scar management begins 24-48 hours after sutures have been removed.
Postoperative
Day 1 (week 1): ROM and nerve gliding exercises, review/education of cervical ROM, shoulder
pendulum exercises and hand tendon gliding exercises should occur. Patients should be
encouraged to use their uninvolved side. Gentle ROM, active, and active assisted ROM should
be started as tolerated. Instruct the patient to perform these exercises holding the position for 5
seconds just before the point of pain or strain. These exercises should be done 3-4 times daily.
Remember drain removal occurs at approximately 3-5 days.
Day 8 (week 2): Sutures are removed and continue gliding exercises for neck and upper
extremity.
Day 15 (week 3): Scar massage and desensitization, possibly the introduction of weights.
Day 22 (week 4): Phonophoresis to scar site, brachial plexus massage, and start strengthening
exercises. This part of the treatment is very individualized depending largely on the patient’s pre
operative activity level. Increases are applied to the program at least weekly while the patient
monitors their pain. If patients are expecting to return to work, an ergonomic and body
mechanic analysis may need to occur. This in combination with adequate strengthening are the
most important to return to a job.
5
Day 29 (week 5): Progress the strengthening exercises
Day 36 (week 6): Ergonomic training, work-simulated activities, possibly a Functional Capacity
Evaluation (FCE) for worker compensated patients.
Day 43-83 (weeks 7-12): Work hardening exercises
Therapy typically lasts 3 months with patients attending 2-3 times per week. A HEP is
necessary from day one. Stretches should occur on a daily basis for at least 2 years because of
scar contraction, which can occur for this duration. Occasionally patients return in 6-12 months
because they do not keep up with their HEP. This course of therapy usually includes
phonophoresis to reduce inflammation and scarring. Again, a thorough review of posture,
stretching, and strengthening exercises needs to occur because TOS can usually be prevented.
Precautions: Patients should not lift more than 5 pounds until 6 weeks post-operative. Therapist
should not push patient through increased or new pain. If swelling occurs at surgical site, in the
involved upper extremity or periscapular area, report immediately to surgeon or supervising
physician. Report any increased heat, redness, marked increased pain or drainage from the
surgical site, as well as any onset of headache, dizziness, numbness in hands, feet, groin, or low
back pain that is new. Symptoms lasting longer than 2 hours would indicate a need for the
therapist to modify the exercise program.
Selected References:
Landry GJ, Moneta GL, Taylor LM, Edwards JM, Porter JM. Long-term functional outcome of
neurogenic thoracic outlet syndrome in surgically and conservatively treated patients. Journal of
Vascular Surgery. 2001;33:312-319.
Marinoni EC, Bonfiglio G, Boletti M, Passarelli O. Thoracic Outlet Syndrome: Proposed

Protocol for Diagnosis and Treatment. Institute of Clinical Orthopaedics and Institute of
Vascular Surgery, University of Milan. Pgs. 379-386.
Sanders RJ, Hammond SL. Supraclavicular first rib resection and total scalenectomy: technique
and results. Hand Clin. 2004;20:61-70.
Toso C, Robert J, Berney T, Pugin F, Spiliopoulos A. Thoracic outlet syndrome: influence of

personal history and surgical technique on long-term results. European Journal of Cardio-
thoracic Surgery. 1999;16:44-47.
Walsh, M.T. Therapist management of thoracic outlet syndrome. J Hand Therapy. 1994;7:131-
144.
Wishchuk JR, Dougherty CR. Therapy after thoracic outlet release. Hand Clin. 2004;20:87-90.

Physical Therpay Protocols For Conditions of Neck Region

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Red Flags for Potential Serious Conditions in Patients with Head and Neck Problems

Red Flags for the Head and Neck Region

Joe Godges DPT, MA, OCS KP So Cal Ortho PT Residency

NAME: __________________________________________ DATE: _____________

1. Are you currently being treated for high blood pressure?

2. Have you recently had difficulty with speaking?

3. Have you noticed an increased clumsiness or weakness in your arms or

4. Do you frequently have headaches?

5. Have you noticed a recent decreased ability of concentrate?

6. Do you experience dizziness?

7. Have you noticed a recent change in your vision or ability to see?

8. Have you recently experienced a blow to the head or a whiplash injury?

9. Have you been experiencing nausea and/or vomiting?

12. Do you have a depressed immune system?

13. Are your eyes sensitivity to light?

14. Have you recently had a seizure?

Joe Godges DPT, MA, OCS KP So Cal Ortho PT Residency

ICD-9-CM code: 723.1 Cervicalgia

Common Historical Findings:

Physical Examination Procedures:

Cervical Accessory Movement Test

Joe Godges DPT, MA, OCS 1 KP So Cal Ortho PT Residency

Cervical Accessory Movement Test

Joe Godges DPT, MA, OCS 2 KP So Cal Ortho PT Residency

Etiology: The cause of this dysfunction is believed to be a movement abnormality where a

Acute Stage / Severe Condition: Physical Examinations Findings (Key Impairments)

• Unilateral posterior-to-anterior pressures at the involved segment reproduce the

As above with the following differences:

Settled Stage / Mild Condition Physical Examinations Findings (Key Impairments)

As above with the following differences:

Joe Godges DPT, MA, OCS 3 KP So Cal Ortho PT Residency

Intervention Approaches / Strategies

Acute Stage / Severe Condition

Goal: Restore painfree active spinal mobility

Joe Godges DPT, MA, OCS 4 KP So Cal Ortho PT Residency

Sub Acute Stage / Moderate Condition:

• Approaches / Strategies listed above – focusing on:

Note: Performing upper cervical joint mobilization/manipulations with the

Settled Stage / Mild Condition:

• Approaches / Strategies listed above

Joe Godges DPT, MA, OCS 5 KP So Cal Ortho PT Residency

Goal: Return to desired occupational or leisure time activities

• Approaches / Strategies listed above

Jull G, Trott P, Potter H, Zito G, Niere K. Shirley D, Emberson J, Marschner I, Richardson C. A

Joe Godges DPT, MA, OCS 6 KP So Cal Ortho PT Residency

Joe Godges DPT, MA, OCS 7 KP So Cal Ortho PT Residency

The following reference provides additional information regarding this procedure:

Joe Godges DPT, MA, OCS 8 KP So Cal Ortho PT Residency

The following reference provides additional information regarding this procedure:

Joe Godges DPT, MA, OCS 9 KP So Cal Ortho PT Residency

Cervical Superior/Anterior Glide

The following reference provides additional information regarding this procedure:

Impairment: Limited Cervical Segmental Rotation

Cervical Rotation in Neutral

The following reference provides additional information regarding this procedure:

Joe Godges DPT, MA, OCS 10 KP So Cal Ortho PT Residency

Cervical Spine Contract/Relax

The following references provides additional information regarding this procedure:

Joe Godges DPT, MA, OCS 11 KP So Cal Ortho PT Residency

Cervical Right Sidebending/Rotation in Flexion

The following reference provides additional information regarding this procedure:

Joe Godges DPT, MA, OCS 12 KP So Cal Ortho PT Residency

NAME: ______________________________ DATE: _