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cervical spine manual therapy

 
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cervical spine manual therapy - September 6, 2006 9:24:00 PM   
rwillcott

 

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I am interested in knowing others treatment techniques for the cervical spine. Specifically, manual therapy techniques for restrictions of this area.

For example, a patient with reduced active right side bending and rotation. All neuro signs are negative. Passive movements of the cervical spine show decreased right side bending of C4 on C5. Tenderness on palpation and hypertonicity at this. Decreased PA mob of C4 on C5 with pain 5/10.

What techniques do others use to treat these types of restrictions? Please be specific when describing the technique and set up.

Thanks,

Rob
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Re: cervical spine manual therapy - September 6, 2006 11:29:00 PM   
Synergy

 

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Rob,

I usually just get my hands on their hypomobile segment and WHACK it some arbitrary direction.

Joking!

I usually begin most of my cervical treatments with the patient supine, their occiput on my thenar/hypothenar eminences, and my fingers on their cranky spot(s). I find that this relaxes them within 3-5 minutes and then further treatment can commence. I rarely if ever manip. the c-spine for fear of injuring the patient (I'll do it on my family members becase they wart me to death) so that 'tool' is not used.

I do like to employ METs to this area and, like Ginger, I'll perform lots of rhythmic PA glides beginning at grades 1-2 and advancing to increasing strengths as the patient tolerates. I'll do a lot of 'skin work' [read: skin stretch] including vertical, horizontal, and oblique patterns from the occiput to the cervicothoracic junction.

After I've done my best to communicate to their brain, I'll attempt some PNF with a combination of isotonics.

I'm sure I'll think of more things after I click 'add reply'.

Interesting topic! :)

_____________________________

Chris Adams, PT, MPT

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Re: cervical spine manual therapy - September 7, 2006 12:49:00 AM   
nari

 

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Chris,
I would do almost exactly as you described, but minus the PNF and isotonics. I keep on forgetting what METS stands for (it seems to be a North American term)but if it is what I think it is, I would spend only about 3 minutes or less with it.
I like the Mulligan-modified touch on the eccentric lengthening side plus eye tracking - the eyes move to the right as far as possible, and then the head follows, with a touch on the lengthening side of the neck (left).
With very short necks, it's trickier...hard to know what is what.

Nari

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Re: cervical spine manual therapy - September 7, 2006 1:04:00 AM   
Synergy

 

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Nari,

Those sneaky acronyms! MET = muscle energy technique. I use the diagonal eye patterns as well...incorporated into my PNF techniques.

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Chris Adams, PT, MPT

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Re: cervical spine manual therapy - September 7, 2006 2:20:00 AM   
nari

 

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Thanks Chris.

Nari

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Re: cervical spine manual therapy - September 7, 2006 2:24:00 AM   
dfjpt

 

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That's pretty much what I do too, including palpate/treat occipital nerves with skin stretch. If rotation is limited, say to the right, I'll also check the right anterior neck. If anterior neck structures feel "tight", I stretch the skin over them, superior-inferior. Gently. Usually that takes care of recovering good rotation/ making anterior neck stuctures feel normal/lengthenable again. If side bend to right is restricted, I do the same on the left.
I follow up by teaching Butler's swivel chair neck rotation for neural glide homework.
Diane

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Re: cervical spine manual therapy - September 7, 2006 8:13:00 AM   
rwillcott

 

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Chris,

How would you peform the MET for this patient? Would you have the patient in sitting or supine? Also, when performing the MET are you blocking certain levels? Are you resisting contralateral sidebending and then takking them further to the right? What is your hand placement?

Nari,

I like the Mulligan technique as well. Do you start with a cranial glide directly on the spinous process before procedding to the lengthening side?

Thanks for the input everyone!

Rob

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Re: cervical spine manual therapy - September 7, 2006 8:26:00 PM   
Synergy

 

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Rob,

For your patient, sitting would be a good place to start. I would block C5 with my left thumb and index finger, being careful not to cause to much discomfort to an alredy sensitive area. My right hand would probably be placed on this patients left parietal area or somewhere in the vicinity. I would then proceed to take up available ROM into either flexion or extension, followed by right SB, and then right rot.

Have the patient perform a submaximal isometric contraction (I usually just tell the patient to match my resistance which is pretty soft...just enough to elicit active movement) for 5-8 seconds and repeat 3-5 times...attempting to 'take up the slack' between each repetition. After this, I'll always re-check the patient's AROM as well as pain via a verbal pain scale.

As far as resisting any specific direction, if one direction doesn't seem to work well, I'll do it again the opposite direction...of course after some rest as this routine can get tiresome for both the patient and yourself.

There's nothing magical at all about METs and I'm sure there's many more options available, but I'm still learning and applying as I go.

Hope this helps! :)

_____________________________

Chris Adams, PT, MPT

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Re: cervical spine manual therapy - September 7, 2006 8:40:00 PM   
nari

 

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Rob,
I don't quite know what you mean by a cranial glide..?

Nari

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Re: cervical spine manual therapy - September 7, 2006 9:04:00 PM   
dfjpt

 

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Nari, I think he means in a cranial direction. As opposed to in a caudal direction, that is.

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Re: cervical spine manual therapy - September 8, 2006 2:11:00 PM   
rwillcott

 

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Nari,

In Mulligans text he describes placing the thumbs on the spinous process of the affected level and apply a glide towards the patients eyes (cranial). He then says to try on either side of the spinous process if this does not work.

Are these the techniques you are describing or is it different?

Thanks,

Rob

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Re: cervical spine manual therapy - September 8, 2006 3:51:00 PM   
nari

 

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No, it sounds much the same.

We always refer to cephalad and caudad - just different terminolgy.

Thanks guys

Nari

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Re: cervical spine manual therapy - September 8, 2006 7:09:00 PM   
rv36116

 

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Check AROM in sitting w/corrected posture for flx/ext/r rot/l rot baselines, check strength of UE's, and since no peripheral symptoms & a clear neuro screen, go through a basic mechanical assessment, based on AROM limitations, go from there, Mckenzie style.

I'd have to know that info before progressing treatment, but sounds as an easy cervical treatment if it's a derangement (change in mechanical symptoms/better/worse days/worse in AM, etc)...

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Re: cervical spine manual therapy - September 8, 2006 7:38:00 PM   
rwillcott

 

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Rob,

In terms of the Mckenzie approach for the cervical spine, I find some patients don't seem to like some of the techniques. For instance, retraction/extension/rotation in sitting can be uncomfortable for the patient.

If it is a derangement that responds to sagittal plave movments which exercises do you tend to send the patient?

Also, if a patient only responds to side bending in the off loaded position which exercise would you send them home with?

I'm just trying to get a sense of what others are doing for this type of patient. Thanks for everyone's input thus far!

Rob

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Re: cervical spine manual therapy - September 9, 2006 12:31:00 AM   
rv36116

 

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I start with clear baselines recorded and see if the patient can tell what deficits they have. I then explain the joint derangement (if the history gives you the idea that it is a derangement) as a door the hinge, and in order for the door (joint) to fully open and close (move in all planes w/o limitations as it was prior to the injury), we have to find the movement that places the door back on the hinges. Or some parallel to fully explain to the patient fully prior to performing any movement.

In order to explain the pain / centralization they may feel, I explain centralization and show the "treat your own neck" booklet where the pain patterns will go from peripheral to central. I also explain that similar to setting a broken bone prior to placing a cast on it which will allow it to heal, getting a joint back in place is painful at times, but specifically central pain is a good pain, peripheralizing pain is not good so we will need to ask for lots of feedback while moving the joint in different directions...

*deep breath* After all the explination has been performed (and pictures shown from netter of the cervical spine & nerves running from the neck down the arms/upper back area), I will take movement baselines in flx/ext/l rot/r rot & qualify their movement by asking if they notice any limitations or pain with each (always being careful never to lead the patient or suggest anything).

Then, if it is obvious with the ROM limitations and sounds like a derangement that may be posterior (no large flx limitation w/o any extension limitation, more than likely an anterior derangement to explore w/flx as the first movement)... I start with closing down the space to make sure there's something posterior in the space (full ext has pain, instead of strain)... this is progressed in the following way:

1. retraction
2. sustained retraction
3. retraction/ext
4. retraction/ext/overpressure
5. retr/ext/overpressure w/rotation & op again
6. sustained retr/ext in prone
7. unloaded followed back to loaded
8. mobs by therapist

-if these produce peripheralization, I would go with lateral movements after making sure to exhaust the sagital plane...

I usually start with lateral flexion, followed by lateral flexion with overpressure followed by rotation/rotation with overpressure and then unloaded - back to loaded... and mobs afterwards.

Probably missing something in here as I'm running low on sleep with my 2 and a half week old daughter :D

Sorry if I did miss something.

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Re: cervical spine manual therapy - September 9, 2006 10:23:00 AM   
rwillcott

 

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Rob PT,

What techniques do you use to avoid leading the patient? I find that patients will ramble a lot about their pain and the effect of the movement. How do you keep them on track without leading them?

Also, what mobs do you use? You mentioned that you finish with a mobilization and I'm curious what technique you are using.

Thanks and hope you get some rest!

Rob

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Re: cervical spine manual therapy - September 9, 2006 2:51:00 PM   
rv36116

 

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Basically, to not lead the patient, after every movement, I ask, is it the same, better or worse (movement & symptom-wise)

give them the three options only. Let them know before-hand that the way it will work is:

1. take baselines
2. perform movement
3. check baselines w/same, better, worse
4. repeat

let them know that is all the information you need from them and from this information collection, it will provide you with the findings needed to address their problem.

The mobs I use when needed are (no order):
1-traction/retraction/extension
2-assistance in sustained retraction
3-lateral flexion mob
4-rotation mob
that's pretty much the cervical summary of what I use (possibly forgetting something in here...) but I find these to be very useful when everything has plateaued w/progression of force.

The biggest key is education,education,education prior to treatment. If they don't understand what you are doing, they won't be compliant. I find that if I educate them and give them parallels to their problem, it makes sense and they are much more compliant than if you give them a movement and show them no results to fix their specific problem.

You can restore movement and help them to that extent, but if their specific problem is not fixed, or they see no changes in it, then they won't be compliant, which is the biggest key to MDT and creating an environment where the patient is given the power to fix themselves.

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Re: cervical spine manual therapy - September 9, 2006 3:34:00 PM   
proud

 

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RobPT,

I have recently changed how I interact with a client during a McKenzie eval. Although I am CertMDT and find the approach one of the more useful ones around, I would hardly say I am sold on all aspects of the tecniques.

For example, given the recent literature with regards to fear avoidance and pain, I find McKenzie assessment way to pain focused. I try to avoid any images of hinges, bulging discs, broken bones, nerves, or putting "something back in place". None of which is known to be true at all. So why plant that seed?

I simply inform the patient that I treat numerous neck and back pain patients with great results( gain confidence), then proceed to tell them that some tissue has been irritated and during the examination, I will be looking for a movement that reduces the tissue irritation. If peripheral symtoms are present, I explain that any "centralization" may cause an increase in pain for the moment, however is a positive indicator for reducing the irritation( I also use the treat your own neck book for a demonstration of centralization, it seems if it is in text...it must be right! But the client's confidence is crucial and that seems to work).

Your thought?

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Re: cervical spine manual therapy - September 9, 2006 3:47:00 PM   
proud

 

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Off topic slightly, but the idea of patient confidence just reminded me of something. Patient confidence has been shown to increase compliance in a PT setting(a no brainer).

I notice several studies in medical journals note dressing attire has a profound impact on patient confidence. Just curious how many guys out there wear ties?

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Re: cervical spine manual therapy - September 10, 2006 12:38:00 AM   
rv36116

 

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I dress very professional, slacks (not khakis) and button up long sleeve shirts and dress shoes.

Not sure about the entire "pain" avoidance, but I want the patient to know the idea of fixing a mechanical fault, and that it can be painful. I never tell them that it's specifically the precise "what is wrong" but more a model of what's happening.

If you're focused on the "pain" aspect with McKenzie, the point of the assessment is missed. It's a rapid change in mechanics instead of pain. Mechanics won't lie, but pain reports can easily distract a therapist.

I agree about the text & pictures being very useful.

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