Cervical Mobilization

2. Cervical Mobilization Kristofferson G. Mendoza, PTRP Department of Physical Therapy College of Allied Medical Professions University of the Philippines Manila All Rights Reserved 2009

3. Learning Objectives By the end of the learning session, the student should be able to: • Explain relevant concepts in cervical mobilization • Explain theoretical rationale behind the effects and use of cervical mobilization • State principles and guidelines related to the proper application of cervical mobilization

4. Learning Objectives • Identify indications, contraindications and precautions in the application of cervical mobilization • Describe cervical mobilization techniques in terms procedure, dosimetry, use and rationale • Identify special considerations in the application of cervical mobilization

5. Learning Objectives • Given a simulated patient care situation, demonstrate cervical mobilization techniques with correct procedure and patient care skills • Given a simulated patient care situation, communicate the treatment rationale, procedure, risk(s) involved, and expected outcome clearly and concisely

6. Review of Relevant Concepts Review of Relevant Concepts

7. Review of Kinematics Shape of Joint Surfaces • Ovoid • Sellar

8. Review of Kinematics Joint Movements • Physiologic • Accessory

9. Review of Kinematics Accessory Movements • Component Motions • Joint Play

10. Review of Kinematics Joint Play (Hertling & Kessler, 1996; Tomberlin & Saunders, 1995) • Distraction • Compression • Sliding / gliding • Rolling • Combined rolling and sliding /gliding • Spinning

11. Review of Kinematics Convex-Concave Rule

12. Review of Kinematics Joint Positions • Open-packed • Closed-packed

13. Review of Relevant Anatomy

14. Review of Relevant Anatomy

15. Review of Relevant Anatomy

16. Review of Relevant Anatomy

17. Review of Mobilization Concepts • Mobilization • Mobilization vs. manipulation • (thrust) • Self-mobilization / • automobilization • Mobilization with movement • (Mulligan’s techniques / • natural apophyseal glides)

18. Review of Mobilization Concepts Barrier concept for normal joint motion and joint motion with somatic dysfunction (Kimberley, 1970)

19. physiologic motion is limited by a physiologic barrier tension develops within the surrounding tissues (joint capsule, ligaments and connective tissue)

20. additional amount of passive range of motion can be performed the anatomic barrier cannot be exceeded without disrupting the joints integrity

21. Cervical Mob Cervical Mob

22. Rationale • Neurophysiological mechanisms for reduction of pain and muscle spasm • Mechanical mechanisms for increase in tissue length, strength and rate ofhealing (via improved nutrition) • Psychological mechanisms for reduction of pain-fear cycle and for placebo effect Harris & Lundgren (1991).

23. Rationale • Improvement of the hydrostatics of the IV disc and vertebral bodies • Enhancement of joint nutrition through increased synovial fluid movement • Activation of type I and II mechano-receptors in the facet joint capsule to influence the spinal gating mechanism

24. Rationale • Alter the activity of the neuromuscular spindle in intrinsic muscles of the segment to affect bias in the grey matter • Assist the pumping effect of the venous plexus of the vertebral segment • Stress reduction on hypermobile joints by mobilizing hypomobile joints

25. Rationale • Enhancement of tissue flexibility, replacement tissue strength, and rate of healing • Enhancement of joint position and motion sense through stimulation of proprioceptors • Placebo / psychological effect (?)

26. Indications • Joint pain and muscle spasm • Reversible joint hypomobility • Positional faults / subluxations* • Progressive limitation • Functional immobility

27. Absolute Contraindications • Bacterial infection in the joint • Malignancy in the area • Spinal cord, cauda equina compression • Recent or unhealed fracture in the area • Osteoporosis • Where technique produces VBI symptoms

28. Relative Contraindications • Joint effusion or inflammation • Arthroses / ankylosis; internal joint derangement (e.g., collagen necrosis of ligaments or capsule in RA) • Nerve root irritation; reproduction of distal symptoms • Joint hypermobility*

29. Relative Contraindications • Excessive pain; irritable conditions • Unhealed fracture in associated areas • Joint hypermobility in associated areas • Newly formed / weakened CT due to injury, surgery or disuse / debilitation • Older people, pregnant women, children

30. Criteria for correct application • Knowledge of relative shapes of joint surfaces (concave or convex) • Duration, type, and irritability of symptoms • Patient and clinician position • Position of joint to be treated Dutton (2004). Orthopaedic examination, evaluation, & intervention. NY: McGraw-Hill.

31. Criteria for correct application • Hand placement • Specificity • Direction of force • Amount of force • Reinforcement of any gains made Dutton (2004). Orthopaedic examination, evaluation, & intervention. NY: McGraw-Hill.

32. Technique Posterior-anterior central vertebral pressure (PACVP or PAs) Indications • Treatment of a painful presentation • For discogenic presentations; • For symptoms occurring centrally and/or bilaterally • In those causing restrictions of movement in the sagittal plane more than other directions

33. Technique Medially and laterally inclined unilateral vertebral pressure Indications • Treatment of a painful presentation, or of resistance present through range • Laterally inclined techniques tend to be more useful in painful presentations • Medially inclined techniques are often more helpful when the aim is to be provocative or to alter resistance • Unilateral technique often useful for unilateral presentations

34. Technique Rotational Mobilization Aim is to produce a pure and localized rotation movement at a given intervertebral level Indications • Unilateral signs and symptoms • Irritable condition rotate away from pain • Assists in improving rotation range of motion • Assists in improving lateral flexion

35. Technique Lateral Flexion Mobilization Aim is to produce a pure and localized lateral flexion at a given intervertebral level Indications • Unilateral signs and symptoms • Irritable condition laterally flex away from pain • Assists in improving lateral flexion • Assists in improving rotation range of motion

36. Technique Longitudinal Traction

37. Glide • Sustained glide (Kaltenborn)

38. Oscillations • Oscillations (Maitland)

39. Oscillations • Oscillations (Maitland)

40. Dosimetry • Sustained distraction, glide 20 sec - 30 sec (In: Dutton, 2004) 6/7 sec -10 sec (In: Kisner & Colby, 2002) • Oscillations 60 - 90 sec(In: Dutton, 2004) 60 - 120 sec(In: Kisner & Colby, 2002)

41. Use Based on Chronicity Grade I and II techniques • acute duration of symptoms Grade II and III techniques • sub-acute duration of symptoms Grade III (or IV) techniques • chronic duration of symptoms

42. Pain-Guided Use Pain is constant even at rest, rises quickly on movement, or appears early in the range and rises to a level sufficient to stop the movement well before the normal limit. Small amplitude, gentle, and confined to the beginning of the available range

43. Pain-Guided Use No pain at rest; pain only begins after more than half the range has been traversed Move into the pain a bit, and even up to the limit with care

44. Pain-Guided Use Block by spasm, more than pain • Grade IV technique, up to the point of spasm so long as it occurs beyond half the range • If pain occurs before that, lower grade • the earlier the spasm, the lower the grade

45. Pain-Guided Use Block by inert tissue tension or compression, with negligible pain or spasm Grade IV technique [grade V technique may be indicated]`

46. Mulligan’s NAGS

47. Mulligan’s NAGS

48. Mulligan’s NAGS

49. SNAGS (Mobilization With Movement) • Mulligan’s SNAG • Application of sustained manual gliding force to a joint with concurrent physiologic motion of the joint, either actively performed by the patient or passively performed by the clinician, with the intent of causing a repositioning of “bony positional faults” αMulligan (1992; 1993). Cited in Dutton (2004). Orthopaedic examination, evaluation, & intervention. NY: McGraw-Hill.

50. SNAGS (Mobilization With Movement) • Force applied parallel to plane of motion • Force sustained throughout movement, until joint returns to starting position • Pain must not be produced at any time during MWM application; otherwise, MWM would be contraindicated Dutton (2004). Orthopaedic examination, evaluation, & intervention. NY: McGraw-Hill.