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

8. Review of Kinematics Joint Movements Physiologic Accessory
Physiological movements are movements the patient can do voluntarily
The 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 ROM
but that cannot be actively performed by the patient.

9. Review of Kinematics Accessory Movements Component Motions Joint Play
Component motions are those motions that accompany active motion but are not under voluntary control. The
term 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 motions
Joint 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 demonstrated
passively, but they cannot be performed actively by the patient
The movements include distraction, sliding,compression, rolling, and spinning of the joint surfaces.
arthrokinematics

10. (Hertling & Kessler, 1996; Tomberlin & Saunders, 1995)
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 vs. manipulation
(thrust)
Self-mobilization /
automobilization
Mobilization with movement
(Mulligan’s techniques /
natural apophyseal glides)
Mobilization are passive, skilled manual therapy techniques applied to joints and related soft tissues at varying
speeds 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 joint
and 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 the
stretch force to the joint capsule.
Mobilization with movement (MWM) is the concurrent application of sustained accessory mobilization applied
by 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.

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 of healing (via improved nutrition)
Psychological mechanisms for reduction of pain-fear cycle and for placebo effect
Neurophysiological
Small-amplitude oscillatory and distraction movements are used to stimulate the mechanoreceptors that may inhibit
the transmission of nociceptive stimuli at the spinal cord or brain stem levels.
Mechanical
Small-amplitude distraction or gliding movements of the joint are used to cause synovial fluid motion, which is the
vehicle for bringing nutrients to the avascular portions of the articular cartilage (and intra-articular fibrocartilage
when 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 pain
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
Static 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)

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 Unilateral signs and symptoms
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 Unilateral signs and symptoms
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

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”
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.

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.

52. Self SNAGS

53. Passive-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 cause
increased 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 bone
The roll without a slide does not replicate normal joint mechanics.
Joint glide (mobilization) stretching procedures, as when the translatoric slide component of the bones
is 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 the
cartilage.
The amplitude of the motion is small yet specific to the restricted or adherent portion of the capsule or
ligaments. Thus, the forces are selectively applied to the desired tissue.

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 tissueα
Gliding apparatus around the nerve trunk
Partially dependent upon the ability of the nerve to move against the surrounding tissue
αMillesi (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
αElvey & Hall (1999). Manual Therapy, 4, Cited in Dutton (2004). Orthopaedic examination, evaluation, & intervention. NY: McGraw-Hill.

60. Relevant 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.

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 testsα; 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*
αElvey. 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 velocityα
αButler (1992). Mobilization of the nervous system. Cited in Dutton (2004). Orthopaedic examination, evaluation, & intervention. NY: McGraw-Hill.

64. Neurodynamic mobilization
Dosimetryα
Initial: passive, gentle, controlled oscillatory movements to the anatomic structures surrounding the neural tissue
Later: stretching of both the surrounding and neural tissues together
αElvey (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 biasα
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)*
Patient in supine
αButler. In: Grant (1994). Physical therapy of the cervical and thoracic spine, 219. Cited in Dutton (2004). Orthopaedic examination, evaluation, & intervention. NY: McGraw-Hill.

68. ULTT2 – radial nerve biasα
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
Patient in supine, elbow extended
αButler. In: Grant (1994). Physical therapy of the cervical and thoracic spine, 232. Cited in Dutton (2004). Orthopaedic examination, evaluation, & intervention. NY: McGraw-Hill.

69. ULTT2 – ulnar nerve biasα
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
Patient in supine
αButler. In: Grant (1994). Physical therapy of the cervical and thoracic spine, 232. Cited in Dutton (2004). Orthopaedic examination, evaluation, & intervention. NY: McGraw-Hill.

70. Self-mobilization
αDutton (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 (4th ed.). Phil: Saunders.
Gorgon, E.J. (2007). Cervical Mobilization Lecture.
Uy, J. (2002). Cervical Mobilization Seminar Handout.

74. Thank You