Manipulations/Mobilizations Flashcards
Which is the only region and state specifically that when performing a lateral flexion assessment do you assess it away from the testing side?
C1-C0 and C1 - C2
What is the only section of the spine when performing lateral flexion leans into the testing side
Lumbar region as noted that Lateral flexion Loves you. Every other region moves awaY
Which segments of the thoracic can act as the lumbar does
T10-T12
The picture shows lateral flexion
How do you perform a Cervical Spine assessment
UPPER Cervical Mobility Scan: Sitting C0-C1 Occipital-Atlantal (Lateral Flexion)
* Patient is sitting
* Practitioner stands behind the patient
* Place the non-palpating hand on top of patients head
* To test for lateral flexion restrictions, place two fingers over the
lateral aspect of the mastoid process
* Laterally flex the head to end range TOWARDS your testing side
* At end range, push on the mastoid process with your 2 fingers
* Normal = Springy feel
* Abnormal = Stiff or really firm
C0-C1 Occipital-Atlantal (Rotation Flexion)
* Patient is sitting
* Practitioner stands behind the patient
* Place the non-palpating hand on top of patients head
* To test for a rotation restriction, place two fingers over the
posterior aspect of the mastoid process
* Rotate the head to end range AWAY from your testing side
* At end range, push on the mastoid process with your 2 fingers
* Normal = Springy end feel
* Abnormal = Stiff or really firm
C1-C0 Atlanto-Occipital (Flexion/Extension only 15 degrees)
* Patient is sitting
* Practitioner stands behind the patient
* Place the non-palpating hand on top of patients head
* To test for flexion/extension restrictions, place the tip of the index finger in the space between the mandibular ramus and the anterior tip of the Atlas(C1) transverse process-Anterior Space
* With your non-palpating hand, move the head into 15 degrees of flexion (Chin to Chest) and feel, with your testing finger, feel for the Anterior space between the mandibular rams and the atlas TVP to close
* Repeat, but this time, move the head into 15 degrees of extension and feel, with your testing finger in the Anterior space, for the space between the mandibular rams and the atlas TVP open
* Abnormal = The space does not open or close due to loss of rolling of the occiput on the atlas
C1-C0 Atlanto-Occipital (Rotation only 15 degrees)
* Patient is sitting
* Practitioner stands behind the patient
* Place the non-palpating hand on top of patients head
* To test for a rotation restrictions, place the tip of the index finger in the space between the mandibular rams and the tip of the Atlas(C1) transverse process - Into the Anterior Space
* With your non-palpating hand, move the head into 15 degrees of rotation, away from your testing finger, and feel, with your testing finger, for the Anterior space between the mandibular rams and the atlas TVP to open
* Abnormal = The space does not open
C1-C0 Atlanto-Occipital (Lateral Flexion only 15 degrees)
* Patient is sitting
* Practitioner stands behind the patient
* Place the non-palpating hand on top of patients head
* To test for a lateral flexion restrictions, place the tip of the index finger between the inferior tip of the mastoid process and the atlas TVP - Into the Posterior Space
* This interspace is difficult to locate because of its small size and the overlying musculature
* Laterally flex the head 15 degrees AWAY from the testing side
* The Posterior space or gap between the mastoid and the Atlas TVP should open up
C1-C2 Atlas with Respect to Axis (Lateral Flexion)
* Patient is sitting
* Practitioner stands behind the patient
* Place the non-palpating hand on top of patients head
* Place testing thumb on the SP of C2 and the index finder on C1 TVP
* With your non-palpating hand, move the head into 15 degrees of lateral flexion, away from your testing finger, and feel, with your testing finger, for the space between the SP of C2 and the TVP of C1 to get larger or increase
* Abnormal = The space does not change
**In this image, there is 15 degrees of lateral flexion towards the contralateral side of testing. It is slight and thus this pic almost looks like there is no movement. **
C1-C2 Atlas with Respect to Axis (Rotation)
* Patient is sitting
* Practitioner stands behind the patient
* Place the non-palpating hand on top of patients head
* Place testing thumb on the SP of C2 and the index finder on C1 TVP
* With your non-palpating hand, move the head into 15 degrees of rotation, away from your testing finger, and feel, with your testing finger, for the space between the SP of C2 and the TVP of C1 to get larger or increase
* Abnormal = The space does not change
What are the Cervical Mobilizations/Manipulation Indications and what are the goals/benefits?
Indications
* Nonspecific Neck Pain
* Headache (Cervicogenic, Tension)
TMJ Disorders
**Goals/Benefits** * Reduce Pain * Restore optimal ROM of segment * Restore quality of movement * Improve proprioceptive function (Via vibratory nature of oscillation activating sensory mechanoreceptors) * Segment specific via contacts placed on or close to segment being mobilized vs Manipulation (Grade 5) tends to have collateral effects. * Improve kinetic chain function * Reduce muscle guarding Compensatory mechanical stress on adjacent structures
What pre-existing conditions are contraindicated for manipulations
- Acute Fracture
- Dislocation
- Ligamentous Rupture
- Cervical Joint Instability
- Tumor
- Infection
- Acute Myelopathy
- Post recent surgical procedure
- Acute Soft Tissue Injury
- Osteoporosis
- Ankylosing Spondylitis
- Rheumatoid Arthritis
- Vascular disease
- Vertebral artery abnormalities
- Connective tissue disease
- Anticoagulation therapy
- Vertebrobasilar insufficiency
- Facial or intra-oral anesthesia or paraesthesia
- Visual disturbances
- Dizziness/vertigo
- Blurred vision
- Diplopia
- Nausea
- Tinnitus
- Dysarthria
- Dysphagia
Any symptom listed above aggravated by position or movement of the neck
Rationale:
Acute Fracture / Dislocation / Ligamentous Rupture / Cervical Joint Instability: Manipulation of unstable or injured structures (bones, joints, ligaments) could worsen the injury, lead to increased instability, or cause further damage to the spine or surrounding tissues.
Tumor: Manipulation could risk spreading malignant cells or cause damage to surrounding tissues in the area of the tumor.
Infection: often cause localized inflammation, weakening the tissue structure around the affected area. Manipulation, pressure, or movement in the infected region can further damage these already compromised tissues. This breakdown of barriers allows infectious agents (such as bacteria) to move from one localized area into surrounding healthy tissue.
Risk of Spreading Infection: If there is an infection in the bones (such as osteomyelitis; ), joints (septic arthritis), or soft tissue (cellulitis or abscess), manipulating the area could spread the infection to nearby tissues or even into the bloodstream, causing sepsis or systemic infection. This could become life-threatening.
Weakened Tissue: Infected tissues, whether bone, muscle, or joint, are often inflamed, fragile, and compromised. Manipulation could cause further damage to already weakened structures.
Increased Inflammation: Inflammation is part of the body’s immune response to infection, and manipulating inflamed tissues can worsen the inflammatory response, prolong healing, and exacerbate symptoms.
Acute Myelopathy: This involves spinal cord compression or damage. Manipulation could aggravate the compression and lead to worsening neurological deficits, including paralysis.
Post-Recent Surgical Procedure: The healing tissues are delicate post-surgery, and any pressure or manipulation could disrupt the healing process, cause internal damage, or lead to complications.
Acute Soft Tissue Injury: Acute injuries, such as muscle tears, sprains, or strains, are still healing. Applying manual therapy could further strain the tissue and delay healing.
Osteoporosis: Weak, brittle bones due to osteoporosis are at a high risk of fractures under manual pressure or manipulation.
Ankylosing Spondylitis: This is a type of inflammatory arthritis that causes the spine’s bones to fuse. Chiropractic manipulation could risk injuring already fragile or fused joints.
Rheumatoid Arthritis: This condition causes inflammation of the joints, and any manipulations could exacerbate joint damage or lead to inflammation flare-ups.
Vascular Disease / Vertebral Artery Abnormalities / Vertebrobasilar Insufficiency: Manipulating the cervical spine in individuals with vascular issues, particularly those involving the vertebral or carotid arteries, could lead to a stroke or insufficient blood flow to the brain.
Connective Tissue Disease: These diseases affect the body’s connective tissues, weakening them. Manipulation could easily damage weakened structures, leading to injury.
Anticoagulation Therapy: Patients on blood thinners have an increased risk of internal bleeding, bruising, or hemorrhage during manual therapy.
Facial or Intra-Oral Anesthesia or Paraesthesia / Visual Disturbances / Dizziness / Vertigo / Blurred Vision / Diplopia / Nausea / Tinnitus / Dysarthria / Dysphagia: These neurological symptoms can indicate underlying problems such as vertebrobasilar insufficiency or compression of nerves and arteries. Manipulating the cervical spine can worsen these symptoms and lead to serious complications.
Any Aggravation of Symptoms with Neck Movement: This suggests that spinal manipulation could worsen the underlying condition, making it risky to proceed with treatment without proper diagnosis and caution.
In short, these contraindications are in place because manual therapy could worsen the underlying condition or introduce significant risks such as fractures, worsening of neurological symptoms, tissue damage, or vascular events like strokes. Safe practice involves recognizing when chiropractic care is appropriate and when alternative treatments should be considered.
Facial or Intra-Oral Anesthesia/Paraesthesia
Facial or intra-oral anesthesia/paraesthesia refers to a loss or alteration of sensation in the face or mouth (e.g., numbness or tingling). This can indicate nerve involvement, particularly from the trigeminal nerve, which could be due to conditions like nerve compression, inflammation, or even a vascular problem.
Why it’s contraindicated: These symptoms might be signs of a serious underlying condition such as a nerve impingement or compression of the spinal cord in the cervical region (neck). Manipulation could exacerbate nerve compression, lead to permanent nerve damage, or aggravate the underlying condition.
Visual Disturbances (e.g., Blurred Vision, Diplopia), Dizziness, Vertigo
These symptoms can indicate problems with the vertebrobasilar system, which supplies blood to the brainstem and parts of the cerebellum.
Vertebrobasilar insufficiency (VBI): This condition occurs when blood flow through the vertebral and basilar arteries is reduced. Manipulating the cervical spine can compress these arteries, which could lead to temporary or even permanent damage to the brain due to insufficient blood flow.
Why it’s contraindicated: Manipulation of the cervical spine can exacerbate this blood flow issue, leading to serious complications such as dizziness, loss of balance, nausea, double vision, or even stroke. Sudden movements of the neck, particularly in those with vertebrobasilar insufficiency, can trigger or worsen these symptoms.
Dizziness / Vertigo / Nausea
Dizziness and vertigo are often caused by disturbances in the vestibular system (the inner ear’s balance mechanism), but they can also be related to poor blood flow to the brain due to vertebral artery compression or cervical spine dysfunction.
Why it’s contraindicated: Manipulating the cervical spine can temporarily block or alter blood flow to the brain, potentially worsening these symptoms. If there is an underlying vascular issue or nerve impingement, cervical manipulation could increase dizziness or vertigo, leading to falls or other accidents.
Tinnitus (Ringing in the Ears)
Tinnitus can be caused by a variety of factors, including issues with the cervical spine, temporomandibular joint (TMJ), or cranial nerves, and can sometimes be linked to vascular problems (like vertebrobasilar insufficiency).
Why it’s contraindicated: If tinnitus is related to a vascular or nerve issue in the neck, manipulation could aggravate the condition. In cases where the tinnitus is linked to blood flow problems or nerve compression, chiropractic manipulation of the neck might worsen the symptom.
Dysarthria (Difficulty Speaking) / Dysphagia (Difficulty Swallowing)
Dysarthria (difficulty speaking) and dysphagia (difficulty swallowing) can result from brainstem issues or compression of the cranial nerves that control muscles involved in speech and swallowing. These nerves originate from the brainstem and pass through the cervical region.
Why it’s contraindicated: If these symptoms are present, it could be a sign of brainstem compression or vertebral artery insufficiency. Manipulating the cervical spine in this case could worsen compression or vascular insufficiency, potentially leading to more severe neurological deficits or even a stroke.
Summary
All of the above neurological symptoms, especially those involving vision, dizziness, and difficulties with speech or swallowing, suggest the involvement of cranial nerves, the brainstem, or vertebrobasilar arteries. Any manipulation of the neck in these cases could worsen blood flow or nerve function, leading to potentially serious consequences, such as a stroke or permanent neurological damage.
Thus, it’s crucial to avoid any spinal manipulation until the root cause of these symptoms is fully diagnosed and treated appropriately. Chiropractors and healthcare providers need to rule out conditions like vertebrobasilar insufficiency, cervical myelopathy, or nerve compression before considering manual treatments.
What are the absolute containdications for manipulations?
Absolute Contraindications Relative Contraindications
I. Arthritides
Atlantoaxial instability from any cause, including:
Rheumatoid Arthritis
Down’s Syndrome
Marfan’s Syndrome
Injury such as MVA or head trauma
Congenital laxity or absence of transverse
ligament
II. Bone Weakening & Destructive Bone Disorders/Diseases Due to:
Destructive Bone Disorders
avascular necrosis
malignant bone tumours-neoplasms
infection of the bone at the joint
fractures
anatomical dislocation
Congenital malformation
aplasia of the posterior arch of atlas
os odontoideum
III. Neurological Disorders/Diseases Due to:
Cauda Equina Syndrome
Neurological deficits after cervical spine high velocity
thrust procedures
IV. Circulatory/Cardiovascular Disorders/Diseases Due to:
Recent TIA
Clinical manifestation of vertebral basilar insufficiency
(cervical manipulation).
An aneurysm involving a major blood vessel in the
general area of manipulation.
Calcification of the vertebral artery
An aneurysm involving a major blood vessel.
Anti-coagulant therapy and some blood dyscrasias
Calcification abdominal aorta
V. Miscellaneous
Lack of consent
Drugged/drunk patient
Recent surgery in/near area of planned manipulation
Discopathies: acute and chronic
Lateral stenosis of lumbar spine
Fused vertebrae
Manipulative treatment exacerbates patient’s
condition.
Manipulation is not the appropriate treatment for the
diagnosis
Patient not accepting of manipulative care
Rationale:
I. Arthritides and Atlantoaxial Instability
Conditions like Rheumatoid Arthritis, Down’s Syndrome, Marfan’s Syndrome, and other factors causing atlantoaxial instability make spinal manipulation highly dangerous. Here’s why:
Atlantoaxial Instability: The atlantoaxial joint, located between the first (atlas) and second (axis) cervical vertebrae, is highly susceptible to instability when the ligaments supporting it are compromised.
Rheumatoid Arthritis: This autoimmune condition causes chronic inflammation of the joints, leading to ligamentous laxity, especially at the atlantoaxial joint. This instability increases the risk of spinal cord compression or vertebral artery injury during manipulation.
Down’s Syndrome: People with Down’s syndrome often have congenital ligamentous laxity, especially at the atlantoaxial joint, increasing the risk of spinal cord injury if manipulated.
Marfan’s Syndrome: A connective tissue disorder that leads to weakened ligaments and joint instability, especially in the cervical spine, increasing the likelihood of dislocations or injury during manipulation.
Injury (e.g., Motor Vehicle Accidents or Head Trauma): Trauma can lead to structural damage or ligamentous instability at the atlantoaxial joint, making manipulation risky.
Congenital Laxity/Absence of the Transverse Ligament: The transverse ligament of the atlas holds the dens (odontoid process) of the axis in place. Without it, there is a significant risk of spinal cord injury if the joint is manipulated.
Avascular Necrosis (AVN): AVN refers to the death of bone tissue due to a lack of blood supply. Manipulation could cause further collapse or damage to the necrotic bone.
Malignant Bone Tumors/Neoplasms: Cancer weakens bone structure. Manipulation could cause fractures or dislodge cancerous tissue, leading to metastasis or further systemic spread of the disease.
Spondylolisthesis: In this condition, one vertebra slips over the one below it. Manipulation, especially a posterior-anterior (PA) thrust, can aggravate this misalignment and cause significant nerve compression or instability.
III. Neurological Disorders
Neurological conditions present unique risks during spinal manipulation because of the possibility of exacerbating nerve damage or causing further neurological deficits:
Cauda Equina Syndrome: This is a medical emergency where the nerve roots at the lower end of the spinal cord become compressed. Manipulating the spine in this condition could worsen nerve compression, leading to permanent damage, such as paralysis, loss of bowel and bladder function, or severe sensory loss.
Neurological Deficits Following Cervical Spine Manipulation: If there are pre-existing neurological deficits (e.g., weakness, numbness, or loss of sensation), further manipulation could aggravate these symptoms, causing permanent nerve damage or spinal cord injury.
What are the relative contraindications for manipulations
Congenital malformation
Articular hypermobility-instability
Benign bone tumors
Demineralization of the bone
osteoporosis
osteopenia
long-term steroid use
previous radiation therapy
Calcification of the ligaments of the upper cervical
spine
Spondylolisthesis: No PA thrust/lumbar roll
. Spondylolisthesis:
Considerations: This condition involves the forward displacement of one vertebra over another. Manipulation in the area of spondylolisthesis, especially with posterior-anterior thrusts, can worsen the condition.
Management: No PA thrust or lumbar roll should be performed on the affected segment. Instead, focus on stabilizing exercises for the core and pelvic muscles. Gentle mobilization may be considered at adjacent levels, but never directly on the unstable segment.
Safe When: When stabilization has been achieved through physical therapy or when the condition is mild and managed conservatively. Use LVLA techniques or non-thrust methods only.
- Structural Scoliosis
Structural scoliosis involves a fixed curve in the spine, often caused by underlying changes in the bones, muscles, or ligaments, which are less likely to respond to manipulative treatments.
Manipulations are typically approached with caution in structural scoliosis because:
Increased asymmetry: A forceful spinal manipulation may exacerbate the asymmetry, causing more imbalance in the spine.
Potential for damage: High-velocity, low-amplitude (HVLA) techniques may increase the risk of damage to already compromised tissues or joints.
Altered biomechanics: The curve changes the biomechanics of the spine, which can make traditional manipulative techniques like a lumbar roll less effective or even harmful.
When it might be considered:
In mild to moderate cases, gentle, low-force techniques may be used to manage pain or improve mobility in areas not directly related to the curve.
Soft tissue techniques (e.g., massage, myofascial release) are often more beneficial in scoliosis cases, helping to alleviate muscle imbalances and tightness.
When it’s contraindicated:
In severe scoliosis, especially if there is a significant spinal deformity or if neurological symptoms are present (e.g., nerve impingement), spinal manipulation is generally avoided.
2. Functional Scoliosis
Functional scoliosis is typically caused by muscle imbalances or other factors (e.g., leg length discrepancies, posture issues) that result in a temporary spinal curve. Since the underlying cause is not related to structural changes in the spine, this type of scoliosis can often be corrected once the underlying issue is resolved.
Manipulation might be beneficial in some cases, as long as the goal is to:
Relieve muscle tension and correct the postural imbalances contributing to the functional scoliosis.
Restore mobility to segments of the spine that may have become restricted due to the compensatory curve.
When it might be considered:
Gentle spinal manipulations or mobilization techniques might help relieve tension in muscles pulling the spine out of alignment.
Stretching and strengthening exercises aimed at correcting the functional cause are usually part of the treatment.
Soft tissue work around the spine to address the muscle tightness and imbalance that contributes to the curvature.
When to avoid manipulation:
If there is an underlying condition affecting the spine or if scoliosis has progressed into a more structural form, manipulative techniques could pose a risk.
Key Considerations for Manipulation in Scoliosis or Functional Curves:
Thorough Assessment: Before considering manipulation, a detailed assessment of the spine, the nature of the scoliosis (functional vs. structural), and any associated symptoms is essential. Imaging may be needed for more serious cases.
Gentle Techniques: Even in cases where manipulation might be useful, gentler techniques like mobilization, low-force techniques, or muscle energy techniques are typically favored over high-velocity adjustments.
Address the Root Cause: For functional scoliosis, correcting the root cause (e.g., muscle imbalance, posture) through exercise, stretching, and manual therapy is key.
Alternative Therapies for Scoliosis or Functional Curves:
