2Cervical Mobilization Kristofferson G. Mendoza, PTRPDepartment of Physical TherapyCollege of Allied Medical ProfessionsUniversity of the Philippines ManilaAll Rights Reserved 2009
3Learning ObjectivesBy the end of the learning session, the student should be able to:Explain relevant concepts in cervical mobilizationExplain theoretical rationale behind the effects and use of cervical mobilizationState principles and guidelines related to the proper application of cervical mobilization
4Learning ObjectivesIdentify indications, contraindications and precautions in the application of cervical mobilizationDescribe cervical mobilization techniques in terms procedure, dosimetry, use and rationaleIdentify special considerations in the application of cervical mobilization
5Learning ObjectivesGiven a simulated patient care situation, demonstrate cervical mobilization techniques with correct procedure and patient care skillsGiven a simulated patient care situation, communicate the treatment rationale, procedure, risk(s) involved, and expected outcome clearly and concisely
7Shape of Joint Surfaces Review of KinematicsShape of Joint SurfacesOvoidSellar
8Review of Kinematics Joint Movements Physiologic Accessory Physiological movements are movements the patient can do voluntarilyThe term osteokinematics is used when these motions of the bones are described.Accessory movements are movements in the joint and surrounding tissues that are necessary for normal ROMbut that cannot be actively performed by the patient.
9Review of Kinematics Accessory Movements Component Motions Joint Play Component motions are those motions that accompany active motion but are not under voluntary control. Theterm is often used synonymously with accessory movement.upward rotation of the scapula and rotation of the clavicle, which occur with shoulder flexion,rotation of the fibula, which occurs with ankle motionsJoint play describes the motions that occur between the joint surfaces and also the distensibility or “give”in the joint capsule, which allows the bones to move.The movements are necessary for normal joint functioning through the ROM and can be demonstratedpassively, but they cannot be performed actively by the patientThe movements include distraction, sliding,compression, rolling, and spinning of the joint surfaces.arthrokinematics
17Review of Mobilization Concepts Mobilization vs. manipulation(thrust)Self-mobilization /automobilizationMobilization with movement(Mulligan’s techniques /natural apophyseal glides)Mobilization are passive, skilled manual therapy techniques applied to joints and related soft tissues at varyingspeeds and amplitudes using physiological or accessory motions for therapeutic purposes.Thrust is a high-velocity, short-amplitude motion such that the patient cannot prevent the motion.The motion is performed at the end of the pathological limit of the jointand is intended to alter positional relationships, snap adhesions, or stimulate joint receptors.Self-mobilization refers to self-stretching techniques that specifically use joint traction or glides that direct thestretch force to the joint capsule.Mobilization with movement (MWM) is the concurrent application of sustained accessory mobilization appliedby a therapist and an active physiological movement to end range applied by the patient.Passive end-of-range overpressure, or stretching, is then delivered without pain as a barrier.
18Review of Mobilization Concepts Barrier concept for normal joint motion and joint motion with somatic dysfunction (Kimberley, 1970)
19physiologic motion is limited by a physiologic barrier tension develops within the surrounding tissues(joint capsule, ligaments and connective tissue)
20additional amount of passive range of motion can be performed the anatomic barrier cannot be exceeded without disrupting the joints integrity
22RationaleNeurophysiological mechanisms for reduction of pain and muscle spasmMechanical mechanisms for increase in tissue length, strength and rate of healing (via improved nutrition)Psychological mechanisms for reduction of pain-fear cycle and for placebo effectNeurophysiologicalSmall-amplitude oscillatory and distraction movements are used to stimulate the mechanoreceptors that may inhibitthe transmission of nociceptive stimuli at the spinal cord or brain stem levels.MechanicalSmall-amplitude distraction or gliding movements of the joint are used to cause synovial fluid motion, which is thevehicle for bringing nutrients to the avascular portions of the articular cartilage (and intra-articular fibrocartilagewhen present). Gentle joint-play techniques help maintain nutrient exchange and thus prevent the painful and degenerating effects of stasis when a joint is swollen or painful and cannot move through the ROM.Psychological benefits of manual therapy that have been reported related to such factors as "the laying on of hands” the application of a faith healer's hands to the patient's body faith cure, faith healing - care provided through prayer and faith in God reducing a pain-fear cycle, and the charisma of the clinician.Avoid worry, which leads to fear and more painHarris & Lundgren (1991).
23RationaleImprovement of the hydrostatics of the IV disc and vertebral bodiesEnhancement of joint nutrition through increased synovial fluid movementActivation of type I and II mechano-receptors in the facet joint capsule to influence the spinal gating mechanismStatic position and sense of speed of movement (type I receptors found in the superficial joint capsule)Change of speed of movement (type II receptors found in deep layers of the joint capsule and articular fat pads)
24RationaleAlter the activity of the neuromuscular spindle in intrinsic muscles of the segment to affect bias in the grey matterAssist the pumping effect of the venous plexus of the vertebral segmentStress reduction on hypermobile joints by mobilizing hypomobile joints
25RationaleEnhancement of tissue flexibility, replacement tissue strength, and rate of healingEnhancement of joint position and motion sense through stimulation of proprioceptorsPlacebo / psychological effect (?)
27Absolute Contraindications Bacterial infection in the jointMalignancy in the areaSpinal cord, cauda equina compressionRecent or unhealed fracture in the areaOsteoporosisWhere technique produces VBI symptoms
28Relative Contraindications Joint effusion or inflammationArthroses / ankylosis; internal joint derangement (e.g., collagen necrosis of ligaments or capsule in RA)Nerve root irritation; reproduction of distal symptomsJoint hypermobility*
29Relative Contraindications Excessive pain; irritable conditionsUnhealed fracture in associated areasJoint hypermobility in associated areasNewly formed / weakened CT due to injury, surgery or disuse / debilitationOlder people, pregnant women, children
30Criteria for correct application Knowledge of relative shapes of joint surfaces (concave or convex)Duration, type, and irritability of symptomsPatient and clinician positionPosition of joint to be treatedDutton (2004). Orthopaedic examination, evaluation, & intervention. NY: McGraw-Hill.
31Criteria for correct application Hand placementSpecificityDirection of forceAmount of forceReinforcement of any gains madeDutton (2004). Orthopaedic examination, evaluation, & intervention. NY: McGraw-Hill.
32Technique Posterior-anterior central vertebral pressure (PACVP or PAs) IndicationsTreatment of a painful presentationFor discogenic presentations;For symptoms occurring centrally and/or bilaterallyIn those causing restrictions of movement in the sagittal plane more than other directions
33TechniqueMedially and laterally inclined unilateral vertebral pressureIndicationsTreatment of a painful presentation, or of resistance present through rangeLaterally inclined techniques tend to be more useful in painful presentationsMedially inclined techniques are often more helpful when the aim is to be provocative or to alter resistanceUnilateral technique often useful for unilateral presentations
34Technique Rotational Mobilization Unilateral signs and symptoms Aim is to produce a pure and localized rotation movement at a given intervertebral levelIndicationsUnilateral signs and symptomsIrritable condition rotate away from painAssists in improving rotation range of motionAssists in improving lateral flexion
35Technique Lateral Flexion Mobilization Unilateral signs and symptoms Aim is to produce a pure and localized lateral flexion at a given intervertebral levelIndicationsUnilateral signs and symptomsIrritable condition laterally flex away from painAssists in improving lateral flexionAssists in improving rotation range of motion
41Use Based on Chronicity Grade I and II techniquesacute duration of symptomsGrade II and III techniquessub-acute duration of symptomsGrade III (or IV) techniqueschronic duration of symptoms
42Pain-Guided UsePain 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
43Pain-Guided UseNo 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
44Pain-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 rangeIf pain occurs before that, lower gradethe earlier the spasm, the lower the grade
45Pain-Guided UseBlock by inert tissue tension or compression, with negligible pain or spasm Grade IV technique [grade V technique may be indicated]`
49SNAGS (Mobilization With Movement) Mulligan’s SNAGApplication 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”Mulligan’s NAGS and SNAGS are based on belief that “bony positional faults” can contribute substantially to painful joint restrictions.αMulligan (1992; 1993). Cited in Dutton (2004). Orthopaedic examination, evaluation, & intervention. NY: McGraw-Hill.
50SNAGS (Mobilization With Movement) Force applied parallel to plane of motionForce sustained throughout movement, until joint returns to starting positionPain must not be produced at any time during MWM application; otherwise, MWM would be contraindicatedDutton (2004). Orthopaedic examination, evaluation, & intervention. NY: McGraw-Hill.
53Passive-Angular vs. Joint-Glide stretching What is the score?Passive-angular stretching procedures as when the bony lever is used to stretch a tight joint capsule, may causeincreased pain or joint trauma because:The use of a lever significantly magnifies the force at the joint.The force causes excessive joint compression in the direction of the rolling boneThe roll without a slide does not replicate normal joint mechanics.Joint glide (mobilization) stretching procedures, as when the translatoric slide component of the bonesis used to stretch a tight capsule, are safer and more selective because:The force is applied close to the joint surface and controlled at an intensity compatible with the pathology.The direction of the force replicates the sliding component of the joint mechanics and does not compress thecartilage.The amplitude of the motion is small yet specific to the restricted or adherent portion of the capsule orligaments. Thus, the forces are selectively applied to the desired tissue.
54Cervical Mobilization Within the Total Care Plan Acute carePRICEMEM protocolSub-acute care; chronic careGentle oscillations, moist heat for relaxationGlide stretch prior to angular stretchDynamic spinal stabilization techniquesActive use of new rangeAutomobilization at home,
55Is there evidence that joint mobilization is better than angular stretching in increasing range of motion in patient’s with burn injuries of the neck?
56Upper Limb Neurodynamic Mobilization Kristofferson G. Mendoza, PTRPDepartment of Physical TherapyCollege of Allied Medical ProfessionsUniversity of the Philippines ManilaAll Rights Reserved 2008
58Relevant BackgroundPeripheral nerves can adapt to different positions via passive movement relative to the surrounding tissueαGliding apparatus around the nerve trunkPartially dependent upon the ability of the nerve to move against the surrounding tissueαMillesi (1986). Hand Clinics, 2, Cited in Dutton (2004). Orthopaedic examination, evaluation, & intervention. NY: McGraw-Hill.
59Relevant Background Proposed mechanisms for dysfunction Dural adhesions produce excessive tension in the neuromeningeal system, which results in limited movement and pain; possible culprits α: Abnormal posture Direct trauma Extremes of motion Electrical injury Nerve compressionαElvey & Hall (1999). Manual Therapy, 4, Cited in Dutton (2004). Orthopaedic examination, evaluation, & intervention. NY: McGraw-Hill.
60Relevant Background Double-crush injuriesα Serial compromise of axoplasmic flow (focal lesions) along the same nerve fiber, causing a subclinical lesion at the distal site to become symptomatic (because of denervation)αUpton & McComas (1973). Lancet, 2, Cited in Dutton (2004). Orthopaedic examination, evaluation, & intervention. NY: McGraw-Hill.
61Common Sites of Compromise Low cervical region (highly mobile)T5-7 (narrowest spinal canal)L4-5 (strongly tethered to neural ligaments)Elbow and wrist (superficial / mobile joints)PiriformisHead of fibulaAnkle joints
62Neurodynamic Mobility Testing Brachioplexus (upper limb) tension testsα; slump test; lower limb tension testsApplication of controlled mechanical and compressive stresses to the dura and other neurological tissues, both centrally and peripherallyExplained by Breig’s “tissue-borrowing” phenomenon*αElvey. In: Glasgow & Twomey (1979). Aspects of manipulative therapy, Cited in Dutton (2004). Orthopaedic examination, evaluation, & intervention. NY: McGraw-Hill.
63Neurodynamic mobilization Rationale To improve axonal transport; ergo, to improve nerve conduction velocityααButler (1992). Mobilization of the nervous system. Cited in Dutton (2004). Orthopaedic examination, evaluation, & intervention. NY: McGraw-Hill.
64Neurodynamic mobilization DosimetryαInitial: passive, gentle, controlled oscillatory movements to the anatomic structures surrounding the neural tissueLater: stretching of both the surrounding and neural tissues togetherαElvey (1999). Manual Therapy, 4, Cited in Dutton (2004). Orthopaedic examination, evaluation, & intervention. NY: McGraw-Hill.
65Neurodynamic mobilization Principles of TreatmentIntensity depends on the irritability of the tissue, patient’s response and changes in symptomsIf restriction is primarily tension, stretch force is held 15 to 20 seconds, released then repeated several timesTingling or numbness should not last when stretch is released
66Neurodynamic mobilization Principles of TreatmentPosition patient to the point of tension , then actively or passively more one joint in the pattern in such a way as to stretch then release the tensionAfter several treatments and the tissue response is known, self-stretching is taught
67ULTT1 – median nerve biasα Shoulder girdle depressionGlenohumeral abduction (~110 deg)Wrist and finger extensionForearm supinationShouler ERElbow extensionCervical lateral flexion toward or away from the test UE (sensitizing maneuver)*Patient in supineαButler. In: Grant (1994). Physical therapy of the cervical and thoracic spine, 219. Cited in Dutton (2004). Orthopaedic examination, evaluation, & intervention. NY: McGraw-Hill.
68ULTT2 – radial nerve biasα Shoulder girdle depressionGlenohumeral abduction (~10 deg),Forearm pronationInternal rotation (or ER*)Wrist, finger, and thumb flexionCervical lateral flexion toward or away from the test UEPatient in supine, elbow extendedαButler. In: Grant (1994). Physical therapy of the cervical and thoracic spine, 232. Cited in Dutton (2004). Orthopaedic examination, evaluation, & intervention. NY: McGraw-Hill.
69ULTT2 – ulnar nerve biasα Wrist, finger, and thumb extensionForearm supinationElbow flexion (full)Shoulder girdle depressionGlenohumeral abduction (slight)Cervical lateral flexion toward or away from the test UEPatient in supineαButler. In: Grant (1994). Physical therapy of the cervical and thoracic spine, 232. Cited in Dutton (2004). Orthopaedic examination, evaluation, & intervention. NY: McGraw-Hill.