Practical 4

Question 1

Diagnose the OA

Answer 1

Grab patient’s head, test translation (NOT rotation or sidebending) motion from side to side in both flexion and extension. The direction that the translation occurs more easily indicates sidebending to the opposite direction (if it translates right, then the OA is sidebent left) and the flexion/extension is determined based on where the translation is more symmetric (if it translates to each side equally in flexion, then the OA is flexed). Rotation is assumed to be opposite of the sidebending

Question 2

Treat the OA with HV/LA

Answer 2

“De-translate technique”; put the patient’s head where you found the restriction (if it was flexed and sidebent left, then you would put the patient’s head in extension and translate them to the right – going into the barrier), then have the patient push their head into your hand, away from the restriction (so in the above scenario, they would push their head to the left), then repeat to the fourth barrier.

Question 3

Diagnose the AA

Answer 3

Make sure you’re STANDING. Fully flex the patient’s head, and then rotate the head to both sides, WITHOUT losing the full flexion. You only have to diagnose rotation, and it’s based on the ease of motion (so, if the patient’s head rotates further to the right, it’s rotated right)

Question 4

Treat the AA with ME

Answer 4

Fully flex and rotate the head into the barrier (away from the way it’s rotated – so if the patient’s AA is rotated right, you will rotate their head left) and have them turn their head the opposite direction into your hand, repeating to the fourth barrier

Question 5

Diagnose the lower cervical spine

Answer 5

Place hands on either side of the neck at the articular pillars, put the head into flexion and extension until the level you’re testing is engaged, then translate (anteromedial motion) the vertebrae from side to side. Repeat for C2-C7. The direction that the translation occurs more easily indicates sidebending to the opposite direction (if C3 translates right, then it is sidebent left) and the flexion/extension is determined based on where the translation is more symmetric (if C3 translates to each side equally in flexion, then it is flexed). Rotation is assumed to be the same as the sidebending.

Question 6

Treat the lower cervical spine with ME

Answer 6

Use the pincer grab to isolate the level being treated, then reverse the diagnosis (for C3 FRLSL, you would extend, rotate right, and sidebend left) until motion is felt at the level. Have patient turn back to neutral, and repeat until fourth barrier.

Question 7

Treat the lower cervical spine with HV/LA

Answer 7

Since you cannot reverse both the sidebending and rotation, you get to pick which way you sidebend the head. I recommend setting it up so that your dominant hand will be applying the rotational HV/LA force.
Firmly press your lateral index finger into the posterior articular pillar of the vertebra that has the dysfunction to create a fulcrum, reverse the flexion/extension, then sidebend the head until you reach a barrier, then rotate the head to the opposite side as the sidebending until you reach the last barrier. Have the patient take a deep breath, and then apply a quick, controlled, and purely rotational force. If it doesn’t crack, you can try again two more times after some fine tuning. If that doesn’t work, you can sidebend the head to the other side and try three more times. If that doesn’t work, see above for ME treatment.
Ex: the patient has C3 FRLSL dysfunction; place index finger on the posterior articular pillar of C3, extend until the C3 level is engaged, sidebend right, then rotate left OR sidebend left, then rotate right.

Question 8

Diagnose the upper cervical spine

Answer 8

Diagnose the AA and C2 as described above.

Question 9

Treat the upper cervical spine as a group with HV/LA

Answer 9

If C2 and the AA both have dysfunctions, you can treat them both using the same HV/LA thrust. Since you can choose which way you sidebend the patient’s head, you can choose to set up the treatment for the C2 dysfunction in the direction that will reverse the rotation of the AA, and it will treat both.

Question 10

Locate and treat posterior cervical tender points: inion

Answer 10

Located 1 inch below the inion in the midline, treat with marked flexion of the neck

Question 11

Locate and treat posterior cervical tender points: PC1

Answer 11

Located ¾ inch lateral to the inion TP, treat by extending the head and rotating/sidebending away

Question 12

Locate and treat posterior cervical tender points: PC2

Answer 12

Located on the superior C2 spinous process, same treatment as C1

Question 13

Locate and treat posterior cervical tender points: PC3

Answer 13

Located on the inferior C2 spinous process, treat by flexing the head and rotating/sidebending away

Question 14

Locate and treat posterior cervical tender points: PC4-PC8

Answer 14

Located on the inferolateral spinous process of the above level, same treatment as C1

Question 15

Locate and treat anterior cervical tender points: AC1

Answer 15

Located posterior and superior on the ramus of the mandible, treat by rotating head away

Question 16

Locate and treat anterior cervical tender points: AC2-AC6

Answer 16

Located on the anterior transverse processes of the level, same treatment as PC3

Question 17

Locate and treat anterior cervical tender points: AC7

Answer 17

Located 1 inch lateral to clavicular head, same treatment as PC3 (flexion – push on middle neck)

Question 18

Locate and treat anterior cervical tender points: AC8

Answer 18

Located on clavicular head (pushing laterally), same treatment as PC3

Question 19

Perform the dural stretch technique

Answer 19

Patient is supine with KNEES BENT. If the patient has a TMJ dysfunction, then grasp the occiput with both hands. If not, then you can grab the occiput with one hand and the mandible with the other. Have the patient breathe in and out, and apply gentle superior traction.

Question 20

Perform the figure 8 mobilization technique

Answer 20

Patient is supine, apply compression through head and move the head in a figure 8 motion.

Question 21

Perform the resistive duction technique

Answer 21

Place hand on either side of the head, front, and back (in series, obviously not all at once…) have the patient push their head gently into your hand, against resistance, ten times in each plane of motion.

Question 22

Locate and treat cervical muscle tender points: levator scapulae

Answer 22

Located on superomedial scapula, treat by flexing the patient’s shoulder and having them place their hand under their chin, apply force along axis of humerus.

Question 23

Locate and treat cervical muscle tender points: trapezii

Answer 23

Located along the upper trapezius, treat by bringing the patient’s arm back to rest it on your monitoring arm, rotate and sidebend the patient’s head towards the TP (if this doesn’t work, try away).

Question 24

Locate and treat cervical muscle tender points: omohyoid

Answer 24

Located at the origin (suprascapular notch), medial to the notch on the scapula, or as it courses over the first rib, treat by bringing the patient’s arm back to rest it on your monitoring arm, rotate and sidebend the patient’s head towards the scapula, then push the hyoid towards the TP.

If the patient has a rotator cuff injury, etc., you can simply passively shrug the shoulder up on the ipsilateral side of the body and repeat above steps.

Question 25

Diagnose and treat the hyoid with MFR

Answer 25

Grab the hyoid bone and translate it left and right; it is translated the way it moves more easily.

Treat by taking it either way, then hold for 15-20 seconds (usually away from the barrier works better).

Question 26

Diagnose the TMJ

Answer 26

Have patient open their mouth slowly and observe their chin for deviation; the deviation will occur to the side of the dysfunction. If the patient’s chin makes an “S”, both sides are restricted.

Question 27

Treat the TMJ with ME

Answer 27

Have the patient open their mouth slightly, and take the chin away from the side of deviation. Have the patient push their chin into your hand and repeat to the fourth barrier.

Question 28

Treat TMJ with intraoral MFR

Answer 28

Put on gloves, have the patient open their mouth and place your thumbs on the superior aspect of the lower molars, pull the jaw anteriorly and inferiorly, hold until release.

Question 29

Diagnose the inlet

Answer 29

Rotation – place fingers in the costoclavicular space and press towards the table, assessing which side is deeper; the rotation is in the direction of the deeper space (deep right = rotated right)

Sidebending – place thumbs on top of the first ribs, apply force towards the patient’s feet; the sidebending is away from the side with the elevated rib (elevated left = sidebent right)

T1 – place index finger on the spinous process of T1 and push up towards the ceiling; if it moves easily, the inlet is extended, but if it doesn’t move easily it’s flexed

Question 30

Treat the inlet with ME

Answer 30

Rotational component – roll patient’s head away from the side of rotation (if they’re rotated right, roll their head to the left) and place lateral fingers behind the cervicothoracic junction, scoop (NOT rotate) the head back until the nose is midline (thumb should rest on their chin), then fine tune (reverse T1 flexion/extension, localize the barrier with sidebending/rotation). Have the patient turn their chin into your thumb to engage the rotatores.

Sidebending component – roll patient’s head towards the side of sidebending (if they’re sidebent right, roll their head to the right) and place lateral fingers on top of the cervicothoracic junction, scoop (NOT rotate) the head back until the nose is midline (thumb should rest on their chin), then fine tune (reverse T1 flexion/extension, localize the barrier with sidebending/rotation). Have the patient push their head into the hand behind them to engage the scalenes.

Note that the inlet being a unit vs. not a unit doesn’t change anything for the ME; you just have to know which way to scoop the head. If the inlet is a unit, these directions will be opposite, but if it is NOT a unit, then the directions will be the same.

Question 31

Treat the inlet with HV/LA

Answer 31

Rotational component – roll patient’s head away from the side of rotation (if they’re rotated right, roll their head to the left) and place lateral fingers behind the cervicothoracic junction, scoop (NOT rotate) the head back until the nose is midline (thumb should rest on their chin), then fine tune (reverse T1 flexion/extension, localize the barrier with sidebending/rotation), then:

If it’s a unit – apply HV/LA thrust purely towards the opposite shoulder.

If it’s not a unit – apply HV/LA thrust towards the inferior, opposite side ribcage.

Sidebending component - roll patient’s head towards the side of sidebending (if they’re sidebent right, roll their head to the right) and place lateral fingers on top of the cervicothoracic junction, scoop (NOT rotate) the head back until the nose is midline (thumb should rest on their chin), then fine tune (reverse T1 flexion/extension, localize the barrier with sidebending/rotation), then:

If it’s a unit – apply HV/LA thrust towards the opposite side ASIS.

If it’s not a unit – apply HV/LA thrust towards the inferior, opposite side ribcage.