Overview of Manual Therapy

Assessment and Treatment of

the Cervicothoracic Spine

Megan Casey Douglas, PT, DPT, MTC, OCS

Megan Casey Douglas, PT, DPT, MTC,

OCS
 Bellingham, WA
 Director of Physical
Therapy at Northwest
Physical Therapy- Skagit
Valley, Private Practice
 Recently moved from
Cincinnati, OH
 DPT, MTC thru University
of St. Augustine
 OCS thru APTA
 MPT – Andrews University
BS- Miami University
 Teaching Experience
 Adjunct University of Dayton
 College of Mt. St. Joseph
 Continuing Education
WHAT IS MANUAL THERAPY?

 A clinical approach utilizing skilled, specific hands-

on techniques, including but not limited to
manipulation/mobilization, used by the physical
therapist to diagnose and treat soft tissues and joint
structures for the purpose of modulating pain;
increasing range of motion (ROM); reducing or
eliminating soft tissue inflammation; inducing
relaxation; improving contractile and non-contractile
tissue repair, extensibility, and/or stability;
facilitating movement; and improving function.1,2
(Definition from American Academy of Orthopedic
Manual Physical Therapy (AAOMPT) and American
Physical Therapy Association (APTA).

Anatomy of the
Cervical Spine

Anatomy of the Cervical Spine

Spinous Process
Articular pillar
formed by
articular process
and interarticular
parts
Zygapophyseal
joints- 45⁰
At T1 – 1st costal
facet for 1st rib
 Mid-Cervical Vertebra
 Body
 Transverse Process C4 Vertebra – vs – C7

 Anterior tubercle
 Posterior tubercle
 Groove for spinal N.
 Transverse foramen
 Pedicle
 Superior articular
facet
 Inferior articular
process
 Vertebral foramen
 Spino s process

Anatomy of C1 and C2

Atlas (c1) Anatomy Axis  (C2)  Anatomy

Ligaments of the Cervical Spine

Posterior view (s.p. removed)
 Tectorial membrane
becomes PLL
 Capsule of OA joint
 Capsule of AA joint
 Capsule of
zygapophyseal joint
 Ligaments of the Cervical Spine

Anterior view

 Anterior
Longitudinal
Ligament

Ligaments of the OA joint

Posterior view

 Alar ligaments
 Cruciate ligament
 Apical ligament of
dens

Cervical Spine Ligaments

Right Lateral View

 Ligamentum
nuchae
 Ligamenta flava
 Spinous process of
C7 vertebra
 Vertebral a.
Cervical Spine Musculature

Cervical Spine Musculature

Cervical Spine Musculature

 Biomechanics of the
Cervical Spine

Biomechanics of the Cervical Spine

Biomechanics of Cervical Spine

 Mid cervical forward

bending
 Facets slide up,
approx. 40%
displacement
 Lateral interbody
joints slide forward
 Vertebrae step
minimally
 Spinal canal narrows
but lengthens, volume
remains the same.
 Biomechanics of Cervical Spine

 Mid Cervical Backward Bending

Facets slide down, then fulcrum on pedicle.
Lateral interbodies slide back
 Vertebrae step considerably!!
Ligamentum flavum bulges inward
Spinal canal shortens and narrows significantly

Cord may be compressed in the presence of

degenerative changes

Biomechanics of Cervical Spine

Mid Cervical Sidebending /Rotation Right

Facets slide down and back on the right
Facets slide up and forward on the left,
causing right rotation

Biomechanics of Cervical Spine

If patient is instructed to face forward with

sidebending Right, AA Rotation Left has
occurred.
If patient is instructed to rotate right,
keeping eyes level with the horizon, SB
Left occurs subcranially (OA, AA).
Approx. half of cervical rotation originates
from the AA joint (C1/C2).
 Anatomy/Biomechanics of the
upper thoracic spine
 T1 has a unifacet
for articulation of
the first rib
 T1 through T3
generally follow
lower cervical
biomechanics
 Lower thoracic
segments similar to
lumbar spine

Cervical Evaluation

Cervical Evaluation

Observation/ Posture
Symmetry, resting position of head on neck
Forward Head Posture (FHP)
Increase/Decrease in thoracic kyphosis
AROM testing
Flexion, Extension, SB R/L, ROT R/L
Veers R/L with flexion/extension
SB R/L, seated, arms supported/ unsupported
Rotation- should recruit down to approx. T3
OA nodding/SB, AA rotation
 Cervical Evaluation
 Neurovascular assessment
 Special Tests
 Alar Odontoid Integrity
 Transverse Ligament
 Vertebral A.??
 Precautions, trauma, diagnostic tests

Cervical Evaluation

 PROM/joint mobility testing

Supine, neutral to slight flexion
OA/ AA mobility
Check SB R/L, Rot R/L
Cervical upglides
Cervical downglides
Upper thoracic joint mobility (from supine, PA)
1st rib mobility
Muscle length, Soft tissue restrictions
Palpation

Cervical Evaluation

Video Demonstration
Cervical upglides
Cervical downglides
Upper thoracic PA mobility
1st rib mobility- depression
 Cervical and Upper
Thoracic Manipulation

Indications for Manipulation

Restricted accessory joint motion

Neurophysiological benefit and pain
control.

Contraindications/Precautions for
Manipulation
Disease states
Hemarthrosis
Hypermobility
Muscle holding
Fracture
Acute inflammation
Fusion/Joint replacement
Anticoagulant therapy
Osteoporosis
 Grades of Manipulation

Grades of Manipulation
 Non-Thrust  Thrust
Maitland- Grade I Traditional- High
Velocity Low
Grade II Amplitude (HVLAT)
Grade III
Grade IV
Traditional- stretch
Paris- progressive  Distraction
Traditional- Manual
oscillation Mechanical
Mulligan- mobilizes Paris- Positional
with active
movement

Cervical Manipulation Techniques-

Video Demonstration
Cervical upglides
Cervical downglides
Upper thoracic PA mobility
1st rib mobility- depression
Cervical Traction
Suboccipital Release/Inhibitive Distraction
 Common Diagnoses that may
benefit from Manual Therapy
Cervical DDD
Cervical OA, facet arthropathy
Cervical Radiculopathy
Disc protrustion/herniation
Foramenal stenosis due to OA
Cervical Sprain/Strain
Cervicogenic Headache

Forward Head Posture can

contribute to...
Muscle Imbalance/ Adaptive shortening
Joint restrictions
Areas of relative hypo/hypermobility
Facet arthropathy
DDD
Compromise of neural foramen
Cervicogenic Headaches
Thoracic Outlet Syndrome
TMJ disorders

Key Tips to Remember

 Treatment to improve
posture/ reduce FHP
and optimize
intended cervical
spine biomechanics
 Treat joint restrictions
with manipulation
 Stabilize areas of
hypermobility
 Avoid manipulative
forces thru
hypermobile
segments
 Key Tips to Remember

 Joint restrictions
may not be where
the patient
complains of
pain/tenderness
 Pain is deceiving/
referral patterns

Key Tips to Remember

After acute phase/palliative treatments, go

to the source of the problem
Disc protrusion- symptom
Muscle “sprain/strain” may be guarding due to
underlying problem
Cervicogenic Headache
FHP?
Joint restriction of OA, AA

Case Study 1
Manual Therapy
Cervical Radiculopathy Treatment
 Patient is a 39 y/o CPA  Acute phase
 Manual traction
(in April!) and has a straight pull
pronounced FHP add slight SB L/ Rot L, flex
 Pain increases Rotation  Suboccipital release

R, SB R, and Ext.  Subacute

 Cervical upglides on R?
 Intermittent R UE  Upper thoracic manipulation
burning down to elbow,  1st rib depression
n/t in R hand  Chronic
 Address other joint
 Weakness in C6 restrictions, soft tissue
restrictions
myotome
 Tenderness over R
 Case Study 2
Manual Therapy
Left Upper Trapezius
Treatment
Strain
 Patient is a 24 y/o  Cervical downglides
student, woke with on Left side
pain on L side of neck
 If c/o pain with
 Pain and decreased L downglide, try cervical
SB and L Rotation
upglides on Right
and Ext. ROM
side.
 Pain and decreased
downglide C3/C4  Recheck joint mobility
facet  Reassess L UT, may
 Trigger point in L UT try
and pain with L UT massage/stretching if

Case Study 3
Cervical DDD, HAs
 Patient is a 58 y/o
female, complaining of
bilateral neck pain and
headaches
 X-rays show DDD at
C5/C6 and C6/C7
 Patient has sedentary
desk job and a
significant
FHP/increased thoracic
kyphosis
 Denies radicular Sx
 Complains of increasing
HAs as work day
Manual Therapy
Treatment
 Posture!
Education/Ergonomics
 Manipulate joint
restrictions- upper/mid
thoracic, upper/mid
cervical?
 Caution: hypermobility at
C5/6, C6/7??
 Suboccipital Release/
Inhibitive distraction
 OA, AA manipulations if
restrictions present- also
may decrease Has
 Address soft tissue
t i ti l

Evidence Supporting Manual

Therapy of the Cervical Spine
 Bronfort G, Haas M, Evans R, Bouter L. 2004 Efficacy of Spinal
Manipulation and Mobilization for Low Back Pain and Neck Pain: a
Systematic Review and Best Evidence Synthesis. The Spine Journal,
4(3):335-56.

 Eldridge L, Russell J. 2005. Effectiveness of Cervical Spine manipulation

and Prescribed Exercise in Reduction of Cervicogenic Headache Pain and
Frequency. International J of Osteopathic Med. 8:106-113.

 Fernandez-de-las-Penas C, Alsonso-Blanco C, San-Roman J, Miangolarra-

Page JC. Methodological Quality of Randomized Controlled Trials of
Spinal Manipulaiton and Mobilzation in Tension-Type Headache, Migraine,
and Cervicogenic Headache. JOSPT 2006 Mar;36(3):160-9.

 Gross A, Hoving J, Haines T, et.al. 2004 A Cochrane Review of

Manpulation and Mobilization for Mechanical Neck Disorders. Spine
29(14):1541-1548.
 Evidence Supporting Manual
Therapy of the Cervical Spine
 Jull G, Trott P, Potter H. et. al. 2002. A Randomized Controlled
Trial of Exercise and Manipulative Therapy for Cervicogenic
Headache. Spine 27(17)1835-1843.

 Lessinck M, Damen L, Verhagen A. et. al. 2004 The Effectiveness

of Physiotherapy and Manipulation in Patinets with Tension-Type
Headache: A Systematic Review. Pain 112:381-388.

 McNair PJ, Portero P, Chiquet C, Mawston G, Lavaste F. Acute

Neck Pain: Cervical Spine Range of Motion and Position Sense
prior to and after Joint Mobilization. Man. Ther. 2007
Nov;12(4)390-4.

 Zito G, Jull G, Story I. 2006. Clinical Tests of Musculoskeletal

Dysfunction in the Diagnosis of Cervicogenic Headache. Man.
Ther. 11(2):118-129.

References

• Anatomy pictures
– Netter, F.H. Atlas of Human Anatomy. 2nd
ed. 1997
• Paris SV. Manipulation and Management
of the Spine. S1 thru S4. University of St.
Augustine, St. Augsutine, FL 32086
• Greenman PE. Principles of Manual
Medicine. Lippincott, Williams, & Wilkins.
Philadelphia, PA. 2003

To comply with professional boards/associations standards:

• I declare that I or my family do not have any financial relationship in any amount, occurring in
the last 12 months with a commercial interest whose products or services are discussed in my
presentation. Additionally all Planner’s involved do not have any financial relationship.
•Requirements for successful completion is attendance for the full session along with a
completed session evaluation form.
•Cross Country Education and all current accreditation statuses does not imply endorsement
of any commercial products displayed in conjunction with this activity.

Overview of Manual Therapy Assessment and

Treatment of the Cervicothoracic Spine
Megan Douglas, PT, DPT, MTC, OCS

Cross Country Education

Leading the Way in Professional Development.
www.CrossCountryEducation.com
Thank You!