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Cervical Mobilization Kristofferson G. Mendoza, PTRP Department of Physical Therapy College of Allied Medical Professions University of the Philippines.

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Presentation on theme: "Cervical Mobilization Kristofferson G. Mendoza, PTRP Department of Physical Therapy College of Allied Medical Professions University of the Philippines."— Presentation transcript:

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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

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

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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

22 Rationale Neurophysiological mechanisms for reduction of pain and muscle spasm Mechanical 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 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 sec (In: Dutton, 2004) 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

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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” α Mulligan (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.

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52 Self SNAGS

53 Passive-Angular vs. Joint-Glide stretching What is the score?

54 Cervical Mobilization Within the Total Care Plan Acute care – PRICEMEM protocol Sub-acute care; chronic care – Gentle oscillations, moist heat for relaxation – Glide stretch prior to angular stretch – Dynamic spinal stabilization techniques – Active use of new range – Automobilization at home,

55 Is there evidence that joint mobilization is better than angular stretching in increasing range of motion in patient’s with burn injuries of the neck?

56 Upper Limb Neurodynamic Mobilization Kristofferson G. Mendoza, PTRP Department of Physical Therapy College of Allied Medical Professions University of the Philippines Manila All Rights Reserved 2008

57 Review of Relevant Neuroanatomy

58 Relevant Background Peripheral nerves can adapt to different positions via passive movement relative to the surrounding tissue α Gliding apparatus around the nerve trunk Partially dependent upon the ability of the nerve to move against the surrounding tissue α Millesi (1986). Hand Clinics, 2, Cited in Dutton (2004). Orthopaedic examination, evaluation, & intervention. NY: McGraw-Hill.

59 Relevant 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 compression α Elvey & Hall (1999). Manual Therapy, 4, Cited in Dutton (2004). Orthopaedic examination, evaluation, & intervention. NY: McGraw-Hill.

60 Relevant Background Double-crush injuries α 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) α Upton & McComas (1973). Lancet, 2, Cited in Dutton (2004). Orthopaedic examination, evaluation, & intervention. NY: McGraw-Hill.

61 Common 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) Piriformis Head of fibula Ankle joints

62 Neurodynamic Mobility Testing Brachioplexus (upper limb) tension tests α ; slump test; lower limb tension tests Application of controlled mechanical and compressive stresses to the dura and other neurological tissues, both centrally and peripherally Explained by Breig’s “tissue-borrowing” phenomenon* α Elvey. In: Glasgow & Twomey (1979). Aspects of manipulative therapy, Cited in Dutton (2004). Orthopaedic examination, evaluation, & intervention. NY: McGraw-Hill.

63 Neurodynamic mobilization Rationale To improve axonal transport; ergo, to improve nerve conduction velocity α α Butler (1992). Mobilization of the nervous system. Cited in Dutton (2004). Orthopaedic examination, evaluation, & intervention. NY: McGraw-Hill.

64 Neurodynamic mobilization Dosimetry α Initial: passive, gentle, controlled oscillatory movements to the anatomic structures surrounding the neural tissue Later: stretching of both the surrounding and neural tissues together α Elvey (1999). Manual Therapy, 4, Cited in Dutton (2004). Orthopaedic examination, evaluation, & intervention. NY: McGraw-Hill.

65 Neurodynamic mobilization Principles of Treatment Intensity depends on the irritability of the tissue, patient’s response and changes in symptoms If restriction is primarily tension, stretch force is held 15 to 20 seconds, released then repeated several times Tingling or numbness should not last when stretch is released

66 Neurodynamic mobilization Principles of Treatment Position 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 tension After several treatments and the tissue response is known, self-stretching is taught

67 ULTT1 – median nerve bias α Shoulder girdle depression Glenohumeral abduction (~110 deg) Wrist and finger extension Forearm supination Shouler ER Elbow extension Cervical lateral flexion toward or away from the test UE (sensitizing maneuver)* α Butler. In: Grant (1994). Physical therapy of the cervical and thoracic spine, 219. Cited in Dutton (2004). Orthopaedic examination, evaluation, & intervention. NY: McGraw-Hill. Patient in supine

68 ULTT2 – radial nerve bias α Shoulder girdle depression Glenohumeral abduction (~10 deg), Forearm pronation Internal rotation (or ER*) Wrist, finger, and thumb flexion Cervical lateral flexion toward or away from the test UE α Butler. In: Grant (1994). Physical therapy of the cervical and thoracic spine, 232. Cited in Dutton (2004). Orthopaedic examination, evaluation, & intervention. NY: McGraw-Hill. Patient in supine, elbow extended

69 ULTT2 – ulnar nerve bias α Wrist, finger, and thumb extension Forearm supination Elbow flexion (full) Shoulder girdle depression Glenohumeral abduction (slight) Cervical lateral flexion toward or away from the test UE α Butler. In: Grant (1994). Physical therapy of the cervical and thoracic spine, 232. Cited in Dutton (2004). Orthopaedic examination, evaluation, & intervention. NY: McGraw-Hill. Patient in supine

70 Self-mobilization α Dutton (2004). Orthopaedic examination, evaluation, & intervention. NY: McGraw-Hill.

71 Contraindications Recent onset or worsening of neurological signs Cauda equina lesions Injury to the spinal cord

72 Is there evidence that neural mobilization is effective in decreasing pain in patient’s with chronic brachial plexus injury?

73 Sources  Kisner C, & Colby LA (2002). Therapeutic exercise: Foundations and techniques (4th ed.). PA: FA Davis.  Dutton (2004). Orthopaedic examination, evaluation, & intervention. NY: McGraw-Hilll  Magee (2002). Orthopedic physical Assessment (4 th ed.). Phil: Saunders.  Gorgon, E.J. (2007). Cervical Mobilization Lecture.  Uy, J. (2002). Cervical Mobilization Seminar Handout.

74 Thank You


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