Cervical Cervical MobilizationMobilization

Kristofferson G. Mendoza, PTRPDepartment of Physical Therapy

College of Allied Medical ProfessionsUniversity of the Philippines Manila

All Rights Reserved 2009

Learning ObjectivesBy 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

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

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

Review of Review of Relevant Relevant ConceptsConcepts

Review of Relevant Concepts

Review of Kinematics

Shape of Joint Surfaces

• Ovoid

• Sellar

Review of Kinematics

Joint Movements

• Physiologic

• Accessory

Review of Kinematics

Accessory Movements

• Component Motions

• Joint Play

Review of Kinematics

Joint Play(Hertling & Kessler, 1996; Tomberlin & Saunders, 1995)

• Distraction

• Compression

• Sliding / gliding

• Rolling

• Combined rolling and sliding /gliding

• Spinning

Review of Kinematics

Convex-Concave Rule

Review of Kinematics

Joint Positions

• Open-packed

• Closed-packed

Review of Relevant Anatomy

Review of Relevant Anatomy

Review of Relevant Anatomy

Review of Relevant Anatomy

Review of Mobilization Concepts

Mobilization Mobilization vs. manipulation (thrust)

Self-mobilization / automobilization

Mobilization with movement (Mulligan’s techniques / natural apophyseal glides)

Review of Mobilization Concepts

Barrier concept for normal joint motion and joint motion with somatic dysfunction (Kimberley, 1970)

physiologic motion is limited by a physiologic barrier

tension develops within the surrounding tissues (joint capsule, ligaments and connective tissue)

additional amount of passive range of motion can be performed

the anatomic barrier cannot be exceeded without disrupting the joints integrity

Cervical MobCervical Mob

Cervical Mob

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).

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

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

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 (?)

Indications• Joint pain and muscle spasm

• Reversible joint hypomobility

• Positional faults / subluxations*

• Progressive limitation

• Functional immobility

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

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*

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

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.

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.

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

TechniqueMedially 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

TechniqueRotational MobilizationAim 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

TechniqueLateral Flexion MobilizationAim 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

Technique

Longitudinal Traction

Glide• Sustained glide (Kaltenborn)

Oscillations• Oscillations (Maitland)

Oscillations• Oscillations (Maitland)

Dosimetry• Sustained distraction, glide

20 sec - 30 sec (In: Dutton, 2004)

6/7 sec -10 sec (In: Kisner & Colby, 2002)

• Oscillations60 - 90 sec (In: Dutton, 2004)

60 - 120 sec (In: Kisner & Colby, 2002)

Use Based on ChronicityGrade 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

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

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

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

Pain-Guided Use

Block by inert tissue tension or compression, with negligible pain or spasm

Grade IV technique [grade V technique may be indicated]`

Mulligan’s NAGS

Mulligan’s NAGS

Mulligan’s NAGS

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”

αMulligan (1992; 1993). Cited in Dutton (2004). Orthopaedic examination, evaluation, & intervention. NY: McGraw-Hill.

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.

Self SNAGS

Passive-Angular vs. Joint-Glide stretching

• What is the score?

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

,

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?

Upper Limb Neurodynamic Mobilization

Kristofferson G. Mendoza, PTRPDepartment of Physical Therapy

College of Allied Medical ProfessionsUniversity of the Philippines Manila

All Rights Reserved 2008

Review of Relevant

Neuroanatomy

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, 651-663. Cited in Dutton (2004). Orthopaedic examination, evaluation, & intervention. NY: McGraw-Hill.

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 postureDirect traumaExtremes of motionElectrical injuryNerve compression

αElvey & Hall (1999). Manual Therapy, 4, 63-73. Cited in Dutton (2004). Orthopaedic examination, evaluation, & intervention. NY: McGraw-Hill.

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, 359-362. Cited in Dutton (2004). Orthopaedic examination, evaluation, & intervention. NY: McGraw-Hill.

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

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, 105-110. Cited in Dutton (2004). Orthopaedic examination, evaluation, & intervention. NY: McGraw-Hill.

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.

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, 63-73. Cited in Dutton (2004). Orthopaedic examination, evaluation, & intervention. NY: McGraw-Hill.

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

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

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)*

αButler. 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

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

αButler. 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

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

αButler. 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

Self-mobilization

αDutton (2004). Orthopaedic examination, evaluation, & intervention. NY: McGraw-Hill.

Contraindications

• Recent onset or worsening of neurological signs

• Cauda equina lesions• Injury to the spinal cord

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

Sources Kisner C, & Colby LA (2002). Therapeutic Kisner C, & Colby LA (2002). Therapeutic

exercise: exercise: Foundations and techniques Foundations and techniques (4th ed.). PA: FA Davis.(4th ed.). PA: FA Davis.

Dutton (2004). Orthopaedic examination, Dutton (2004). Orthopaedic examination, evaluation, & intervention. NY: McGraw-Hilllevaluation, & intervention. NY: McGraw-Hilll

Magee (2002). Orthopedic physical Magee (2002). Orthopedic physical Assessment (4Assessment (4thth ed.). Phil: Saunders. ed.). Phil: Saunders.

Gorgon, E.J. (2007). Cervical Mobilization Gorgon, E.J. (2007). Cervical Mobilization Lecture.Lecture.

Uy, J. (2002). Cervical Mobilization Seminar Uy, J. (2002). Cervical Mobilization Seminar Handout.Handout.

Thank You