nick buratovich, nmd€¦ · • rust's test or sign: patient asked to lay down, if has to...

$: NICK BURATOVICH, NMD€¦ · • RUST'S TEST or SIGN: Patient asked to lay down, if has to support neck/head may indicate a severe injury with muscle, ligament, disc, vertebral fracture$
MSDWMANIPULATION SKILL

DEVELOPMENT WORKSHOPSUBOCIPUT

CERVICAL SPINENICK BURATOVICH, NMD

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MSDW - Manipulation Skill Development Workshop • SUBOCIPUT CERVICAL SPINE Instructor: Nick Buratovich, NMD • TheBoneDance.com

THE CERVICAL SPINE

• APPLIED ANATOMY:• The cervical spine is composed of two segments, anatomically

and functionally. There are 7 vertebrae.• It is an area in which stability has been sacrificed for mobility,

making the C-spine particularly vulnerable to injury. NOTE: rotation past 50 degrees ( nl is 50-80) may lead to kinking of the vertebral artery. This may lead to vertigo, nausea, tinnitus, visual disturbances, TIA’s or stroke. (Vertebral Artery Test)

• There are 14 facet (apophyseal) joints. They are synovial joints.

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Cervical Spine Orthopedic Tests

• VALSALVA: Hold breath and bear down. Increases intrathecalpressure, declaring a space occupying lesion, eg. disc, mass, or osteophyte.

• DEJERINE'S TRIAD: Strain / Cough / Sneeze.• SWALLOWING TEST: Have patient swallow. Positive with pain

indicating esophageal or pharyngeal injury or anterior injury to C-spine, disc or ALL.

• COMPRESSION: < Root , disc or facet injury. May modify with ROM.

• DISTRACTION: < Strain or sprain and joint capsulitis.• SHOULDER DEPRESSION: Local pain = muscle or ligament

injury. Radiating pain = compression or stretching of neurovascular bundle (adhesions of dural sleeves/nerve roots), TOS.

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• ADSON'S TEST: Radial pulse amplitude baseline, turn head toward side tested, may hold breath, turn head toward opposite side. + is decrease in amplitude due to neruovascular bundle compression (subclavian artery / brachial plexus) or scalenes muscle spasm.

• WRIGHT'S TEST: Radial pulse amplitude baseline. Hyperabductand extend arm, may turn head toward side, + is decrease in pulse amplitude due to compression of axillary artery or pectoralis minor muscle spasm.

• ROOS Test: (E.A.S.T. test): Arms are held up and the fist is opened and closed for 3 minutes looking for downward drifting of the affected side.

• SPINAL PERCUSSION: Tap SP's with reflex hammer. Local pain may indicate fracture or sprain, radiating pain indicating disc lesion. Pain while tapping paraspinal muscles may indicate strrain.

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• L'HERMITTE'S SIGN: Sitting with legs extended, flex C and T spine. Shooting pain = disc lesion, cord disease, meningitis. Local pain = S / S

• RUST'S TEST or SIGN: Patient asked to lay down, if has to support neck/head may indicate a severe injury with muscle, ligament, disc, vertebral fracture or dislocation.

• VERTEBRAL ARTERY TEST: Patient lays down extends/rotates head and holds for 20 - 30 seconds. This compresses the vertebral artery on the opposite side of head rotation and checks the patency on the same side as the rotation. + = vertigo, dizziness, visual blurring, naseau, faintness, nystagmus.

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Cervical Spine Orthopedic Tests• SOTO - HALL TEST: Stabilize sternum, passively flex neck. Local

pain = strain/sprain, bone pathology or injury, cord disease. Radiating pain = disc lesion.

• BAKODY’S SIGN: (aka Monkey Sign) With an upper cervical disc or nerve root injury if the patient puts their hand/forearm on the top of their head it will relieve the pain. With a lower cervical disc or nerve root issue the patient will feel better holding their arm held close to the abdomen.

• CERVICAL RANGE OF MOTION:• Flexion: 30 - 50 degrees• Extension: 30 - 60 degrees• Lateral flexion: 40 - 45 degrees• Rotation: 50 - 80 degrees

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PHYSICAL EXAM OF THE CERVICAL SPINE

• BONY PALPATION:• ANTERIOR:

• Hyoid bone (C3)• Thyroid cartilage (Adams Apple) (C4‐C5)

• POSTERIOR:• Occiput / Inion• Mastoid processes• TP C1• SP C2• Facet joints (C5/6 most involved in pathology)• C7 / T1 Vertebrae prominens

• SOFT TISSUE PALPATION:• SCM muscle, lymph node chain, trapezius muscle, suboccipital muscles

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MOBILITY ASSESSMENT OF THE CERVICAL SPINE

CERVICAL ROTATION TEST AS A WHOLE:• Ask the patient to relax their head and neck and to allow you to

passively turn it to either side. Ask them to relax through the ark of movement. Choosing either to begin with the right or left side rotate the cervical spine from a neutral position to the right or left side. Assess the ark of motion and the range. Turn the head and neck back to neutral center and assess the other direction. Make sure to have the patient relax and not assist you as it should be a passive assessment. Assess and compare the range of motion from the right to the left.

• If the patient notices pain or you appreciate restriction in movement, there is usually a lesion of some sort. At this point you cannot tell whether it is a soft tissue or osseous restriction or which side may be involved. Although you know that there is a lesion of some sort.

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MOBILITY ASSESSMENT OF THE CERVICAL SPINE

CERVICAL LATRERAL BENDING AS A WHOLE:• Ask the patient to relax their head and neck and to allow you to passively

laterally bend their head and neck to the corresponding shoulder. Assess the ark of motion and the range. Bring the head back to center and check the other side making sure the patient is relaxed as the movement should be passive. Assess and compare the range of motion.

• If the patient notices pain or your appreciate restriction in movement, there is usually a lesion of some sort

• The patient is supine and the doctor grasps the head with the thenareminencies on the crown of the head and the fingers supporting the skull through the occipital and temporal bones. The doctor compresses and pushes on the head while lifting the head. A fully mobile neck will exhibit 3 distinct motion “steps”. Less than 3 steps indicates a restriction. The first step correlates to the upper segment of the cervical spine, the second step to the middle segment of the cervical spine and the third step to the lower segment of the cervical spine.

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ROTATION AND LATERAL BENDING OF THE CERVICAL SPINE AS A WHOLE

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SEGMENTAL EVALUATION OF THE CERVCIAL SPINE

• Segmental evaluation means checking each individual facet joint.• LATERAL BENDING:

• The doctor places his index fingers along the articular pillar of the cervical spine in a supine patient. While one hand supports the head and neck the other palpating hand, through the index finger, applies a lateral pressure through the facet joint of the level being evaluated. This pressure is applied, in a segmental fashion, from the upper cervical spine to the lower cervical spine. When one side is completed the other side is evaluated. The doctor is feeling for a loss of joint play and glide which is felt as a restriction in the movement of the facet joint to right or left lateral bending.

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LATERAL BENDING

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SEGMENTAL EVALUATION OFTHE CERVICAL SPINE

• Segmental evaluation means checking each individual facet joint:• ROTATION:

• The doctor places his index fingers along the articular pillar of the cervical spine in a supine patient. One hand holds the head and neck in a position of rotation using a cradle hold while the palpating hand, through the index finger, applies a rotatory pressure through the facet joint of the level being evaluated. This pressure is applied, in a segmental fashion, from the upper cervical spine to the lower cervical spine. When one side is completed the other side is evaluated. The doctor is feeling for a loss of joint play and glide which is felt as a restriction in the movement of the facet joint to right or left rotation.

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ROTATION

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THRUST HAND POSITION

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INDIFFERENT HAND POSITION

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Supine Lower Cervical Technique • The contact and indifferent hand position the head and neck so that a

“pivot” is formed at the contact point in the direction of the greatest restriction.

• Laterally bend and rotate the head away from the doctor.

• Cervical vertebrae release more easily while passively “dropping backward”.

• Pre-thrust mobilization may be a gentle, irregular or regular slow-paced rocking and gentle stretching into and out of rotation and lateral flexion. This is used to facilitate relaxation and may not be needed in a fully relaxed patient. It minimizes the possibility of trauma from the procedure by preparing the tissues for the motion and thrust by stretching them and circulating tissue fluid.

• In the lower cervicals it may be helpful to circumduct the neck and allow it to drop toward the shoulder on the side of contact.

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Thrust Mechanics• To prepare for thrust mechanics gently roll the head into

position for manipulation (after pre-mobilization) toward the direction of restricted motion and take out the tissue slack by applying pressure in the contact hand and moving anterior in a rotatory direction onto the lesion site. Maintain contact with established tissue traction while applying traction and mobilization into rotation and lateral flexion. Use contact to insure that motion is focused at the desired joint/level. Apply thrust after mobilizing and while still under traction into the direction of greatest restriction or mis-alignment.

• Maintain the tension between the contact and indifferent hands• Don’t scissor • Commit, don’t hesitate with the thrust

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Supine Cervical Technique -Line of Drive Middle Cervicals

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Supine Cervical Technique -Line of Drive Lower Cervicals

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SUPINE LOWER CERVICAL TECHNIQUE

• In all contacts:• Relaxation is prerequisite• Use minimal, but necessary force• Gentle, passive, rocking motion may assist in obtaining relaxation, but lock correct position in the moment

before the thrust• Isolate motion pivot at your contact point• Individualize degree of rotation and/or lateral flexion• Minimize extension and rotation, maximize lateral bending• Try to leave the head, in your indifferent hand, on the table. ie. Have your indifferent hand lay on the table• Minimize the pressure on the lesion as pain will increase patient tension• Try not to ‘hold’ for to long as that will increase patient tension

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Prone Cervical Manipulation• Contacts: Proximal or distal index. May use first MCP.

• Listing of lesion: Posterior rotation of the cervical segment. (laminae and articular process)

• Assessment: Palpate a posterior segment of the lower cervical spine. The facet joint will be posterior and feel prominent, the spinous process will rotate away from the posteriority. There may be a fixation or loss of joint play on the involved side. There may be an associated sense of tenderness to palpation as well as fibrosis of the soft tissue of a thickening of the osseous structures.

• CH: Contact is on the ipsilateral laminae and articular process with the thrusting hand. The doctor may stand, in the fencer’s position, either facing cephalad or caudad. As the doctor takes contact in a downward direction, taking out the osseous and soft tissue slack, the patient turns his head and neck in the opposite (contralateral) direction of the lesion. This is done in one fluid motion while maintaining contact throughout the technique.

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PRONE C‐SPINE MANIPCEPHALAD

SET UP CONTACT INDIFFERENT HAND CONTACT

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PRONE C‐SPINE MANIP:THRUSTCEPHALAD

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PRONE C‐SPINE MANIPCAUDAD

SET UP CONTACT INDIFFERENT HAND CONTACT

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PRONE C‐SPINE MANIP:THRUSTCAUDAD

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Prone Cervical Manipulation• NB: If the lesion is on the left side and the doctor is facing

cephalad the CH is the left hand. If the doctor is facing caudad, the CH is the right hand.

• IH: The indifferent hand is placed over the patients temporal /parietal zygomatic arch area. Avoid the TMJ. Pressure is applied to secure the skull onto the table.

• THRUST: The thrust is lateral and inferior through the lesion to restore the lost motion or to reposition the posteriority of the articular facet (joint). The thrust is delivered in one quick rapid motion using the shoulder girdle and torso. The doctor’s arm should be behind the thrust “pushing” the lesion through the restriction and/or into proper alignment.

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ATLAS - C1/AXIS - C2

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VERTEBROBASILAR ARTERY SYNDROME

This is usually due to compression or cerebrovascular arteriosclerosis of the vertebral artery or cervical spondylosis. This is accentuated by rotation and extension of the cervical spine. Symptoms usually include anxiety, dizzyness, vertigo and nystagmus. This may be diagnosed through the vertebral artery test.

May also consider auscultation of the internal carotid for a bruit or the use of a doppler study.

The vertebral artery is the largest branch of the subclavian artery. They join to become the basilar artery and along with the internal carotids form the Circle of Willis.

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LIGAMENTOUS SUPPORT OF THE UPPER CERVICAL SPINE

• ALAR LIGAMENT:• Connects the dens with occipital condyle and the lateral mass of the atlas• Its function is to limit axial rotation in O‐C1 / C1‐C2

• CRUCIFORM LIGAMENT:• Consists of the horizontal transverse ligament of the atlas and connects the lateral masses of the atlas to the dens

• Its function is to limit the rotation of C1/C2 and to protect the spinal cord from the dens

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VERTEBROBASILAR ISCHEMIA

• 5 D’s And 3 N’s• Dizziness, vertigo, or light‐headedness• Drop attacks (sudden fainting)• Diplopia (double vision) or other visual problems• Dysarthia (speech difficulty)• Dysphagia (difficulty in swallowing)• Ataxia (unsteadiness) of gait or hemiparesis (lack of voluntary movement on one side of the body)

• Nausea or vomiting• Numbness or hemianesthesia (lack of sensation on one side of the body)• Nystagmus

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UPPER CERVICAL PATTERNS• In relationship to the O – C1 joint the

palpatory reference is the mastoid process and the lateral mass of C1. The pattern of fixation is usually where one side is contracted or “jammed” together, and the other side is stretched or “gapped” apart. C1 is often laterally displaced toward the jammed side.

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UPPER CERVICAL PATTERNS

• JAMMED SIDE (less space/inferior occiput)• Posterio‐lateral sub‐occipital muscles are hypertonic and often tender• Trigger points are common• Occiput is laterally flexed towards the jammed (fixated) side• Atlas (C1) tends to shift ipsilaterally (same side as the jam)• Harder to palpate the inferior occiput

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UPPER CERVICAL PATTERNS

• GAPPED SIDE (more space)• Posterio‐lateral sub‐occipital muscles are stretched and loose• Trigger points are uncommon• Occiput is laterally flexed towards the jammed side• Atlas (C1) tends to shift medially (toward the jammed side)• Easier to palpate the inferior occiput

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PRE MANIPULATIVE SOFT TISSUE RELAXATION TECHNIQUES

• Bowstring traction• Bridging traction• Suboccipital traction• Neuromuscular trigger point treatment

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Bowstring traction

The fingers pull the cervical extensor muscle group laterally. 37


Bridging traction

The fingers create a bridge which contacts the posterior arch of C1.

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Suboccipital traction

The thenar eminences contact the suboccipital region applying a long axis traction force.

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ASSESSMENT: O –C1• Occiput – C1:

• Using digital contact (index finger most common) find the mastoid process, then drop inferior and anterior with palpating finger to contact the TP of C1. You may move posterior to palpate the lateral mass of C1. Try to appreciate the space between the mastoid process and the TP of C1, feeling for a jam or a gap. You may also check for lateral displacement of C1 or rotation. If palpation is difficult due to tight muscles (SCM) you may push the TP of C1 between the two index fingers to create a “ballotment” of motion (joint play) which usually makes identification easier. The pattern of fixation is usually where one side is contracted or “jammed” together, and the other side is stretched or “gapped” apart. C1 is often laterally displaced or rotated toward the jammed side.

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ASSESSMENT C1 – C2

• C1 – C2: Using digital contact with index or middle finger contact palpate mobility of the articular process (facet joint) between C1 and C2 unilaterally and bilaterally. Cradle the occiput with the palm and fourth and fifth digits while resting thumbs on the zygomatic arch. The index (or middle finger) contact acts as a sensor for mobility while the rest of hand contact moves the head in rotation and lateral flexion to assess motion in C1 / C2.

• Position, tissue texture changes and tenderness are also evaluated.

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MANIPULATIVE TECHNIQUEOCCIPUT – C1/ USING C1 AS CONTACT

• PP: Supine, LESION SIDE DOWN• DP: Dr. is at head of table in fencer’s position with their body in a straight line behind the contact hand• CH: Contact is taken with Dr’s hand on lateral mass/TP of C1 on side opposite to lesion. May use distal index or thumb. Contact side is up. With an index contact the remaining fingers cradle the occiput on the side of contact. This helps to stabilize the movement of C1. With a thumb contact the remaining fingers are fully extended resting on the patient’s cheek.

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C1 AS CONTACTLESION SIDE DOWN

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MANIPULATIVE TECHNIQUEOCCIPUT – C1/ USING C1 AS CONTACT• IH: The index finger of the IH cradles the occipital ridge in ulnar deviation contra‐laterally to the side of contact, creating a slight lift and traction.• T: Tissue traction is taken to the throat with rotation and lateral bending to isolate O/C1. The thrust is taken so as to jam the gap and therefore gap the jam. The direction is cephalad in a line towards the patient’s eye/nasal/oral area. It is a sharp thrust of high velocity and low amplitude and is specific in direction. • This technique is successful when the patient is fully relaxed. To help them do this, have them focus on relaxing the shoulder on the side of contact. Move the head passively and gently prior to thrust to test for relaxation (PTM)

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Supine Cervical Technique -Line of Drive Upper Cervical’s

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MANIPULATIVE TECHNIQUEC1 – C2

• PP: Supine, LESION SIDE UP• DP: Dr. is at head of table in fencer’s position with their body in a straight line behind the contact hand• CH: Contact is taken with Dr’s hand on articular pillar (facet) of C1 / C2 on lesion side. May use distal index or thumb. Contact side/lesion side is up. With an index contact the remaining fingers cradle the occiput on the side of contact. This helps to stabilize the movement of C1. With a thumb contact the remaining fingers are fully extended resting on the patient’s cheek.

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MANIPULATIVE TECHNIQUEC1 – C2

• IH: The index finger of the IH cradles the occipital ridge in ulnar deviation contra‐laterally to the side of contact/lesion, creating a slight lift and traction.• T: Tissue traction is taken to the throat with rotation and lateral bending to isolate C1/C2. The direction is cephalad in a line towards the patient’s eye/nasal/oral area. It is a sharp thrust of high velocity and low amplitude and is specific in direction. • This technique is successful when the patient is fully relaxed. To help them do this, have them focus on relaxing the shoulder on the side of contact. Move the head passively and gently prior to thrust to test for relaxation (PTM)

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MANIPULATIVE TECHNIQUE0‐C1/C1‐C2

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Sub-occipital TechniqueOcciput-C1 using the Occiput as contact

• L: To release a jammed O - C1. Jammed side is positioned on tabled side. Lesion side down and using the occiput as the contact.

• PP: Supine. LESION SIDE DOWNDP: Dr. is a head of table off toward side of contact.

• IH: Reaches around and supports the jaw while rotating the head away and using the forearm to lift and traction the underside occiput (lesion side). The fingers interlace with the contact hand’s fingers around the mouth.

• CH: Dr’s web of thumb and index finger contacts gapped (upside) sub-occipital area. The thumb hooks the sub-occipital area while the fingers rest on the cheek and around the mouth. The forearm lines up parallel with the sternum.

• T: A long axis extension traction is applied then a thrust is added in the same direction with a superior lift to release the jammed undersurface occiput. The CH and IH are both involved in the thrust.

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SUB‐OCCIPITAL TECHNIQUE

SET UP THRUST

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Sitting Cervical Technique• Sitting cervical technique: May be used at all cervical levels.

• Listing: ROTATION and lateral flexion (coupled motion C3-C7) restriction in cervical spine

• PP: Patient is seated. Dr. is standing, anterior to patient and opposite side of contact, ie opposite side of lesion. (In Gonstead technique the doctor stands behind the patient.)

• CH: If lesion is on left side of pt. Dr. uses right hand. If lesion is on right side of pt. Dr. uses left hand. Fingers wrap around the articular pillar and laminae next to the spinous process of the lesion complex, the latter which are contacted on their posterior aspect. Specific contact is taken by the middle finger on the lamina and articular pillar (facet) of the vertebrae being moved with tissue traction (slack) being taken towards the throat.

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Sitting Cervical Technique• IH: The thumb (thenar eminence) and fingers (palmar aspect) contact and

support the head on the zygomatic arch and occiput opposite to the lesion side. Initial contact of CH is on the lamina of the lesion next to the SP and tissue is tractioned anterio-laterally toward the articular pillar/throat. The neck is laterally flexed toward the side of contact and rotated away from the side of contact. The specific motion resisted is engaged with the fulcrum at the contact point. Extreme lateral flexion is often needed in the set up in order to achieve the desired focal point.

• THRUST: The Dr. “pulls” contact toward him/herself into the resisted motion with a low amplitude, high velocity thrust. The CH and IH work together as a unit. The CH thrusts and the IH “receives”. It is often useful to use a motion-aided relaxation. You may lift the patient’s head in a circular manner as if circumducting it passively, then allowing the head to drop into the corner toward the shoulder side of the lesion side. The thrust is given at the moment the desired pivot is achieved. Because contacts are through many tissue layers you must “reach” in with your visualization when palpating your contact point.

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SITTING CERVICAL

SET UP CONTACT THRUST

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SITTING CERVICAL

SET UP CONTACT THRUST

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SITTING CERVICALHAND POSITIONS

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CERVICAL TRACTION • MANUAL :Axial Distraction

• The second and third digits cradle under the occipital ridge while the thumbs cradle the angles of the jaw (care should be taken not to apply undue force through the jaw, the majority going into the occiput.) Also may try zygomatic arch contact with thumbs. A traction force is gradually applied, held for about 10 seconds to 1-2 minutes, then gradually released. Shorter applications may be repeated several times. Application and release is gradual. Is INDICATED in foramenalencroachment or cervical disc lesions. This resembles the sub-occipital traction hold.

• “LONG AXIS EXTENSION RELEASE”• A light to moderate force in a traction thrust may be added to release

joint dysfunction when there is a sense that the joints of the neck are “jammed together” and do not release with simple holding traction. The same contact would be used.

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LONG AXIS EXTENSION

FINGER CONTACTS THRUST

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nick buratovich, nmd€¦ · • rust's test or sign: patient asked to lay down, if has to...

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