Cervical Manipulation Flashcards
To keep it safe
Small amplitude
Mid range
Localization
Low force
Force Contact point Localized Direction Amplitude Speed
Indications for manipulation - Mechanical
Hypomobility/Motion restriction Joint fixation/acute joint locking Somatic dysfunction Restore bony alignment Meniscoid entrapment/displaced disc fragment/adhesions
Indications for manipulation - Physiological
Pain modulation Reflex relaxation of muscles Reprogramming of the CNS Muscle facilitation Release of endorphins
Strength changes with cervical manipulation - study showed
Scapulothoracic muscle strength changes following a single session of manual therapy and an exercise program in patients with neck pain
Clinical practice guidelines - evidence supports that it helps in those with
Neck pain with mobility deficit (cervicalgia, pain in thoracic spine)
Neck pain with headache (HA, cervicocranial syndrome)
Absolute contraindications - highlighted ones
Bone pathology - ligamentous laxity (alar, transverse, tectorial membrane)
Neurological - cervical myelopathy (cord compression - BB changes, B symptoms, ataxic gait)
Vascular - vertebral artery insufficiency (5Ds And 3Ns), carotid artery dysfunction
Relative contraindications
Adverse reaction to previous MT Disc herniation Spondylolysis, listhesis, advanced DJD Anticoagulants or corticosteroids Psych dependence Lig laxity Pregnancy Arterial calcification Worsening condition
Adverse effects of thrust and non thrust manipulation
Neck pain/soreness Radiating pain Fatigue HA Dizziness Blurred vision Ringing in the ears
Adverse effects of thrust and non thrust manipulation - highlighted ones
Neck pain/soreness (27.7% T, 22.3% NT)
HA (15.6% T, 15.8% NT)
They are both about the same with these side effects
Safety/Prevention - study - Are adverse events preventable and are manipulations being performed appropriately?
If all contraindications and red flags were ruled out:
- 8% of adverse events could be avoided (they had an abs contra)
- 4% inappropriate (it wasn’t indicated)
- 4% unpreventable suggesting some inherent risk
One of the risk factors has to do with anatomy - explain
Vertebral and Carotid arteries
One of the risk factors has to do with anatomy - explain Vertebral artery
11% of cerebral blood flow
Supplies post cranial circulation
Greater stress with upper cervical rotation
(we are never in end range rotation)
One of the risk factors has to do with anatomy - explain Carotid artery
89% cerebral blood flow
Supplies ant cranial circulation
Greater stress with mid cervical extension
(we aren’t putting our patients into ext)
Vertebral artery dissection
Tunica intima can be peeled away from tunica media
Tunica intima itself might occlude blood flow
Thrombus
Thrombus might be formed at site awaiting to release - and then gets released by some cervical motion into the circle of willis
Is it the manipulation that injures the arteries?
Pt example of having the severe arthritis and then osteophyte that hit the artery
Mechanism of VBI - stats
Arterial dissection/spasm Brain stem lesions 43% spontaneous 31% cervical manipulation 16% trivial trauma 10% major trauma
Mechanism of VBI - info
Manipulation might have been administered to pt with a spontaneous dissection in progress
Initial symptoms of acute neck pain and HA for which they seek treatment
Almost 70% of VBI is caused by something other than the manipulation
The risk of serious complications
6/10 million
risk of death 3/10 million
Risk factors - major risk factors for stroke or artery problems
Hypertension Hypercholesterolemia Hyperlipidemia Diabetes Family hx of MI, angina, TIA, CVA, PVD Smoker BMI over 30 Repeated/recent injury Upper cervical instability
Risk factors - minor risk factors for stroke or artery problems
Vit B12/folate deficiency Estrogen based contraceptive Infections Poor diet RA Blood clotting disorders Fibromuscular dysplasia Hypermobility (marfans, EDS) Erectile dysfunction BMI 25-29
Screening for VBI in pts with neck pain - MT decision making in presence of uncertainty - Spinal fractures
Major trauma - MVA, fall from height, direct blow to C spine w/o imaging
Severe limitations during neck AROM in all directions
Screening for VBI in pts with neck pain - MT decision making in presence of uncertainty - Cervical myelopathy
Sensory disturbance of hands MM wasting of intrinsics Unsteady gait Hoffman's reflex Hyperreflexia B/B changes Multisegmental weakness and/or sensory changes
Screening for VBI in pts with neck pain - MT decision making in presence of uncertainty - Neoplastic conditions
Age over 50 Prior history of CA Unexplained weight loss Constant pain - not relieved with bed rest Night pain
Screening for VBI in pts with neck pain - MT decision making in presence of uncertainty - cervical ligamentous instability
Occipital HA and numbness
Cervical mm spasm
Severe limitation in AROM
Signs of cervical myelopathy
Screening for VBI in pts with neck pain - MT decision making in presence of uncertainty - artery insufficiency
Drop attacks Dizziness Dyphagia Diplopia Dysarthria Nausea Numbness Nystagmus
Lightheadedness Perioral altered sensation Loss of visual acuity Impaired sensation of face Altered taste Acute anxiety
Screening for VBI in pts with neck pain - MT decision making in presence of uncertainty - Inflammatory or Systemic disease
Temp over 100 BP over 160/95 HR over 100 RR over 25 Fatigue
Examination of at risk pateints
Vascular check - BP, atherosclerosis risk factors, baseline data, pulse check
Neuro eval - CNs, UMN tests (Clonus, Hoffmans, Rhomberg, Babinski)
BMI, Eye tracking, Ligamentous instbaility, Pre positional testing, Functional pre screening
Transverse ligament
Stabilize C2
Extend backward
Alar ligament
Stabilize C2
LF or Rot
Tectorial membrane
Stabilize C2
flexion and distraction
Evidence - Manipulation for neck pain - long and short term results in thrust and non thrust and with combined interventions - Thoracic vs. Cervical manip for those with neck pain — People we know benefit from thoracic manipulation
Symptoms less than 30 days No symptoms distal to shoulder Looking up - no aggravates Low FABQ (less than or equal to 12) Dec kyphosis at T3 - T5 Ext ROM is less than 30 deg
So took these people - manip thoracic and they do well - already proven
Then they did same criteria for people but manipulated their neck
Both groups got same HEP
NDI score improved for both - but better for those that had cervical manipulation - going straight to where problem is
Functional and pain scales better too
Key points to the thoracic vs cervical study
Pts treated with C spine TJM and Ex showed greater improvement in pain and disability compared to T spine TJM and ex
They also experienced fewer transient post treatment side effects
Can we predict who is likely to benefit from neck joint manipulations - clinical prediction rule
If pts meet 4 criteria = 100% prob of success
3 criteria = 90%
2 criteria = 68%
1 criteria = 43%
If pt doesn’t meet clinical prediction rule?
Does not mean it is contraindicated - just means that you cannot predict success
Can we predict who is likely to benefit from neck joint manipulations - clinical prediction rule - what are the predictor variables
1 Symptoms duration less than 38 days
2 Positive expectation that manipulation will help
3 Side to side difference in cervical rot is 10 degrees or more
4 Pan with PA to mid c spine
Continuous reassessment
During history
During physical exam
During intervention
Following intervention
Norm for coupled movements
Occ/CI = OPP
Below C2 = SAME
Facet apposition locking below C2
Norm is SAME
So to lock will be opp
Upslope - in the direction of
Rotation Inferior facet of the superior vertebrae is moving up - UPSLOPE Primary = rotation Secondary = sidebending PALPATE on opp side of rotation!
Downslope - in the direction of
SB Superior facet of the inferior vertebrae is sliding inferiorly - DOWNSLOPE Primary = SB Secondary = rotation PALPATE on same side of SB
Vertebral artery testing
End range rot 10 sec Neutral 10 sec Other rot 10 sec Neutral 10 sec Ext 10 sec Neutral 10 sec
