Chapter Objectives
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Describe the orientation and function of the anatomic structures in the cervical spine.
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Explain the arthrokinematics and biomechanics of the cervical spine during active range of motion and joint mobilizations.
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Perform special tests for the cervical spine and be able to explain the technique and differentiate positive and negative test findings.
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Appreciate the clinical thought process involved during the evaluation.
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Design and implement a therapeutic program on the basis of clinical findings noted during the evaluation.
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Describe common pathologic conditions in the cervical spine and the therapeutic considerations needed to address the pathology.
The cervical spine is one of the most commonly injured areas in the human body, with pathologies ranging from chronic in nature because of poor postural habits to those occurring as a result of acute, traumatic injuries. Rehabilitation techniques have changed in recent years because of a more thorough understanding of this region. Such understanding has allowed rehabilitation to evolve from structured protocols that have relied solely on static, isometric exercises to programs that address the need for normalization of the tissue’s tolerance of functional loading (forces causing stretching or compression) so that dynamic, isotonic exercises can be instituted to restore postural deficits and regain neuromuscular control, strength, and endurance. This chapter addresses the anatomic, arthrokinematic, and biomechanical considerations needed during the evaluation and treatment process. Differential assessment of the tissues related to the cervical spine and evaluation of joint play and mobility will allow the clinician to determine whether tissue lesions and pathologic hypermobility or hypomobility are present and to address these pathologies with manual techniques and the application of an exercise regimen to expedite the healing process. Various special tests are presented that allow the clinician to determine the specific cause of pain and loss of function. By performing a complete evaluation procedure, the sports rehabilitation specialist will develop a better understanding of the exact tissues involved in the pathology. This will allow the clinician to provide the optimal stimulus to facilitate healing of that tissue.
Anatomy
It is imperative that the clinician be competent in locating and identifying the anatomic structures of the cervical spine and have proficient understanding of their biomechanical functions to allow a thorough evaluation and institute a proper rehabilitation program. Therefore, this section addresses the cervical vertebral column and its surrounding ligaments, muscles, and neurovascular structures. Because various pathologic conditions can affect one or more of these systems, it is important that the rehabilitation specialist have a thorough functional understanding of these structures.
Bony Configuration
The cervical spine consists of seven vertebrae. The anatomic structure of the midcervical spine (C3-C6) is similar to that of the thoracic and lumbar spine in that each vertebra has a vertebral body, pedicle, lamina, and spinous process. However, the midcervical spine also has a number of anatomic structures that are unique to this region ( Fig. 16-1 ). Each midcervical vertebra has an uncinate process and a foramen transversarium, and their spinous processes are bifid. The foramen transversarium accommodates the vertebral artery and vein and is found in all cervical vertebrae except C7, although variations do exist. The spinous processes are bifid to allow greater range of motion (ROM) into extension and to provide a mechanical advantage for muscular attachments.
The superior surface of the vertebral bodies in the midcervical spine is concave in the frontal plane and convex in the sagittal plane, and the opposite is true for the inferior surfaces. These cervical vertebrae have two superior and two inferior facets that are located on the pedicles. The superior facets are oriented in a posterior direction, whereas the inferior facets are oriented in an anterior direction. The biplanar orientation of these joints requires that rotation and lateral flexion be coupled movements. These facets articulate with the adjacent vertebrae to form facet joints (zygapophyseal joints). They have an approximate angle of 45° from the horizontal plane in the midcervical region (C3-C6) that decreases to approximately 30° in the lower cervical region (C7-T3) ( Fig. 16-2 ). The facet joints are planar synovial joints with articular cartilage on the surfaces that is enclosed in a fibrosis joint capsule. Found within the joint capsule is meniscoid, adipose, and connective tissue. The medial branch of the dorsal primary ramus innervates the facet joints.
The first cervical vertebra (C1), the atlas, articulates with the occiput superiorly and the axis (C2) inferiorly. The atlas does not have a spinous process or a real vertebral body; however, the odontoid process (dens) of the axis functions as the body of C1 (see Fig. 16-4 ). The atlas consists of two lateral masses connected by anterior and posterior arches and transverse processes that provide for acceptance of weight through the articular processes. The posterior surface of the anterior arch has a facet lined with hyaline cartilage that articulates with the odontoid process of C2 ( Fig. 16-3 ). The superior articular processes are biconcave and articulate with the biconvex occipital condyles, and the inferior articular processes are biconvex and articulate with the biconvex superior facets of the axis.
The axis (C2) contains a superior projection, the odontoid process, that articulates with the posterior aspect of the anterior arch of the atlas. The axis, like the atlas, has small transverse processes and a posterior arch instead of pedicles ( Fig. 16-4 ). In the upper cervical spine (C1-C2), the foramen transversarium is located more laterally than in the midcervical spine, thus requiring the vertebral artery to ascend in a lateral direction in this region. Weight bearing is absorbed superiorly as the axis articulates with the inferior facets located on the lateral masses of the atlas and is transmitted inferiorly through the inferior facet joints, which are located more posteriorly on the axis, similar to those in the midcervical region.
Uncovertebral joints (joints of Luschka), first described by von Luschka, are believed to develop because of degenerative changes in the annulus fibrosus ( Fig. 16-5 ). They are located on the lateral aspect of the midcervical vertebra and on the posterolateral aspect of C7-T1. Uncovertebral joints function to deepen the articular surface and provide stability as they articulate with the adjacent vertebral body. However, because of their close proximity to the spinal nerves, osteophyte formation in this region can encroach on these structures. They also limit motion, especially lateral flexion, and serve to prevent lateral disk herniation.
Intervertebral Disk
An intervertebral disk (IVD) is present between each cervical vertebra except for the occiput and atlas (C0-C1) and the atlas and axis (C1-C2). The disks in the cervical spine are relatively thicker than those in the thoracic and lumbar spine, which allows greater ROM. The cervical disks are slightly higher anteriorly and thereby contribute to the lordotic curve in the cervical spine. The IVD is divided into a central region, the nucleus pulposus, and a peripheral ring, the annulus fibrosus. No true demarcation is found between the nucleus and the annulus, but rather a gradual change in tissue structure is seen from the inner layer to the outer ring. Because of the collagenous properties of the nucleus pulposus, which contains primarily type II collagen, it functions to resist axial compression and distributes these forces. The annulus fibrosus is composed of primarily type I collagen and functions to resist tensile forces within the disk. As a person ages, the amount of proteoglycan and therefore the amount of water begin to diminish. The IVDs are avascular and depend on diffusion from the vertebral end plates for their nutrition. The disk is innervated along the periphery of the annulus fibrosus through the sinuvertebral nerve.
Nerve Roots
Although there are seven cervical vertebrae, there are eight pairs of nerve roots in the cervical spine. This discrepancy is due to the fact that the first nerve root (C1) exits between the occiput and the atlas and nerves 2 through 7 also exit above the vertebrae for which they are named. The transition of the nerve root exiting below the vertebra for which it derives its name occurs at C8, and this continues throughout the thoracic and lumbar spine. Therefore, because the C5 nerve root exists above the C5 vertebra, protrusion of the C4-C5 IVD would most likely affect this nerve. The cervical nerves differ from the lumbar nerves in that the ventral (motor) and dorsal (sensory) roots do not unite to form a mixed spinal nerve until it is in the intervertebral foramen. Because of this anatomic relationship, cervical disk herniations would be more likely to affect the spinal cord or the ventral root, whereas nerve irritation from the facet or uncovertebral joint could encroach on either the nerve roots or the spinal nerve. The nerve roots then exit the vertebral column in the intervertebral foramen and divide into the anterior (ventral) and posterior (dorsal) primary rami. The posterior primary rami innervate the deep erector spinae muscles and the facet joints. The anterior primary rami of C5-T1 combine to form the brachial plexus supplying the upper part of the arms.
Ligamentous Support
Because the upper cervical spine has sacrificed osteokinematic stability for greater arthrokinematic mobility, it is dependent on ligamentous support to allow basic function and avoid injury. Because of the unique and complex articulations present in the upper cervical region, specialized ligaments provide the needed stability. The dens is connected to the anterior rim of the foramen magnum by the apical ligament and the two obliquely oriented alar ligaments. The alar ligaments limit the amount of contralateral rotation that occurs at the atlantoaxial joint. The cruciform (cruciate) ligament consists of three bands of fibers oriented in superior, inferior, and transverse directions ( Fig. 16-6 ). The transverse band is approximately 7 to 8 mm in thickness, which makes it the largest and strongest of all the atlantoaxial ligaments. The cruciform ligament functions to stabilize the dens against the posterior aspect of the anterior arch of the atlas and to prevent subluxation into the spinal canal. Posterior to the cruciform ligaments is the tectorial membrane. It originates at the basilar occipital bone and forms the continuation of the posterior longitudinal ligament (PLL). The PLL attaches to the IVD of adjacent vertebrae and their vertebral margins and functions to prevent cervical disk herniation and excessive flexion of the vertebral bodies. In the cervical spine the PLL is broader and thicker than in the lumbar spine. The anterior longitudinal ligament (ALL) originates from inferior surface of the basilar occiput bone and extends to the sacrum. It attaches to the vertebral bodies and IVD, but not to the bony rims. This ligament functions in preventing hyperextension of the vertebral bodies.
The posterior vertebral elements have specialized ligaments to provide stability. The ligamentum flavum connects adjoining laminae, and because of its attachment to the anterior aspect of the facet joint, it serves to prevent entrapment of the facet capsule and meniscus in the facet joints. The ligamentum nuchae is posterior to the ligamentum flavum and is a fibroelastic membrane that functions to limit cervical flexion. The posterior cervical ligament originates at the occiput and inserts into the spinous processes of the cervical spine before terminating at C7. It functions to resist excessive flexion and divides the posterior cervical muscles into right and left sides.
Muscular Arrangement
The cervical spine has numerous muscles that have an influence on proprioceptive input and postural control and provide active movements for the occiput, cervical spine, and upper part of the trunk. These muscles can be divided into anterior and posterior groups according to their attachment in relation to the transverse processes. Tables 16-1 and 16-2 list these muscles, including their origin, insertion, action, and innervation.
| Muscle | Origin | Insertion | Action | Innervation |
|---|---|---|---|---|
| Sternocleidomastoid | Sternal head: anterior sternum | Mastoid process | Bilaterally: flexes the head | C2 |
| Clavicular head: medial third of the clavicle | Mastoid process | Unilaterally: side-bends the head toward and rotates the head to the opposite side | Spinal accessory nerve (cranial nerve XI) | |
| Scalene anterior | Anterior tubercles of the transverse processes of C3-C6 | Scalene tubercle of the first rib | Elevates the first rib Unilaterally: side-bends the neck toward and rotates the neck to the opposite side Bilaterally: flexes the neck | C5-C8 |
| Scalene medius | Posterior tubercles of the transverse processes of C2-C7 | Superior surface of the first rib behind the subclavian groove | Elevates the first rib Unilaterally: side-bends the neck toward and rotates the neck to the opposite side Bilaterally: flexes the neck | C3-C4 |
| Scalene posterior | Posterior tubercles of the transverse processes of C4-C6 | Second rib posterior to the attachment of the serratus anterior | Elevates the second rib Unilaterally: side-bends the neck toward and rotates the neck to the opposite side Bilaterally: flexes the neck | C4-C8 |
| Longus capitis | Anterior tubercles of the transverse processes of C3-C6 | Basilar part of the occipital bone | Flexes the head and neck and assists in rotation | C1-C4 |
| Longus colli | Vertebral bodies of C5-T3 and anterior tubercles of the transverse processes of C3-C5 | Vertebral bodies of C2-C4 Anterior tubercle of the atlas Anterior tubercles of the transverse processes of C5-C6 | Flexes the head and neck and assists in rotation Unilaterally: side-bends the neck | C2-C8 |
| Rectus capitis anterior | Lateral mass of the atlas | Basilar part of the occipital bone | Bilaterally: flexes the head Unilaterally: side-bends and rotates the head ipsilaterally | C1-C2 |
| Rectus capitis lateralis | Anterior tubercle of the transverse process of the atlas | Jugular process of the occiput | Bilaterally: flexes the head Unilaterally: side-bends the head | C1-C2 |
| Muscle | Origin | Insertion | Action | Innervation |
|---|---|---|---|---|
| Upper trapezius | Medial third of the superior nuchal line, external occipital protuberance, and ligamentum nuchae | Lateral third of the clavicle | Extends, side-bends, and rotates the head to the opposite side Elevates the scapula | Spinal accessory nerve (cranial nerve XI) C3-C4 |
| Levator scapulae | Transverse processes of the upper 3-4 cervical vertebrae | Medial border of the scapula above the spine | Extends, side-bends, and rotates the neck to the ipsilateral side Elevates and downwardly rotates the scapula | Dorsal scapular nerve (C5) C3-C4 |
| Splenius capitis | Ligamentum nuchae, spinous processes of C7 and upper 4-5 thoracic vertebrae | Mastoid process and superior nuchal line | Extends, side-bends, and rotates the head and neck to the ipsilateral side | C4-C6 |
| Splenius cervicis | Spinous processes of T3-T6 | Posterior tubercles of the transverse processes of the upper 3–4 cervical vertebrae | Extends, side-bends, and rotates the neck to the ipsilateral side | C4-C6 |
| Longissimus capitis | Transverse processes of the upper 4-5 thoracic vertebrae | Mastoid process | Extends, side-bends, and rotates the head to the ipsilateral side | C6-C8 |
| Longissimus cervicis | Transverse processes of the upper 4-5 thoracic vertebrae | Posterior tubercles of the transverse processes of C2-C6 | Side-bends and rotates the neck to the ipsilateral side | C6-C8 |
| Semispinalis capitis | Transverse processes of C7 and upper 6-7 thoracic vertebrae, C4-C6 articular processes | Between the superior and inferior nuchal lines | Extends, side-bends, and rotates the head to the ipsilateral side | C1-C8 |
| Semispinalis cervicis | Transverse processes of the upper 5-6 thoracic vertebrae | Spinous processes of C2-C5 | Extends, side-bends, and rotates the neck to the ipsilateral side | C1-C8 |
| Obliquus capitis inferior | Spinous process of the axis | Transverse process of the atlas | Extends, side-bends, and rotates the head to the ipsilateral side Side-bends and rotates the neck to the ipsilateral side | C1-C2 |
| Obliquus capitis superior | Transverse process of the atlas | Above the inferior nuchal line | Extends and side-bends the head | C1 |
| Rectus capitis posterior major | Spinous process of the axis | Lateral aspect of the inferior nuchal line | Extends, side-bends, and rotates the head to the ipsilateral side | C1 |
| Rectus capitis posterior minor | Posterior tubercle of the atlas | Medial third of the inferior nuchal line | Extends and side-bends the head | C1 |
Biomechanics
The forces and stresses that are controlled and generated by the body ensure the proper histologic, biomechanical, and physiologic properties of each tissue.
“Structure governs function and function dictates structure.”
—Rob Tillman, PT, MOMT
Osteokinematic motion in the cervical spine is a result of interaction of the cervical vertebrae, IVDs, ligaments, joint capsules, and the orientation of the facet joints working together to control and dictate the movements that occur in this region. Active ROM is a result of the interaction of the entire cervical spine to produce a desired movement. However, because of anatomic differences between the upper cervical and midcervical spine, the upper cervical spine is able to perform motions independent of those of the midcervical region. This allows the cervical spine to correctly position the head for optimal orientation of the visual, auditory, and olfactory nervous systems.
The arthrokinematic motions of the upper cervical spine are discussed in detail because of the complex articulations in this region. Notably, the desired motion occurs as a result of these actions occurring in unison. The following processes described are a teaching tool that is meant to promote biomechanical understanding of what occurs, although functionally these movements are occurring together and in synchrony. Because normal variations occur in osseous and connective tissue properties and orientation, structural discrepancies can exist and produce altered arthrokinematic movements.
During flexion of the upper cervical spine ( Fig. 16-7 ), ( 1 ) the convex condyles of the occiput glide in a posterior direction on the concave facets of the atlas, which produces ( 2 ) an anterior tilt of the occiput. ( 3 ) The atlas is pushed approximately 2 to 3 mm in an anterior direction because of the force created in the facet joints. This translation creates approximation between the dens and the transverse ligament, which restricts further motion. ( 4 ) The atlas tilts 15° to 20° anteriorly, ( 5 ) thus causing its anterior arch to move inferiorly 2 to 4 mm as the posterior arch is elevated. ( 6 ) The superior tilt of the posterior arch increases tension on the posterior ligamentous structures between C1 and C2. ( 7 ) The increased tension causes movement between C2 and C3.
Extension of the upper cervical spine ( Fig. 16-8 ) occurs as a result of ( 1 ) the convex occipital condyles gliding forward on the concave facet joints of the atlas, which produces ( 2 ) a posterior tilt of the occiput. ( 3 ) The compressive forces cause the atlas to translate 2 to 3 mm posteriorly, and such translation is restrained by the anterior arch of the atlas approximating against the odontoid process. ( 4 ) The atlas tilts posteriorly approximately 12°, which causes ( 5 ) its anterior arch to translate 2 to 4 mm superiorly on the dens as the posterior arch moves inferiorly. ( 6 ) As the anterior ligamentous structures become taut, ( 7 ) the axis glides posteriorly on C3.
Right lateral flexion of the upper cervical spine ( Fig. 16-9 ) is produced as the convex condyles of the occiput glide 3° to 5° to the left, which causes a relative right translation of the atlas. This translation is prevented as the dens approximates against the lateral mass of the atlas. Lateral flexion between C1 and C2 does not occur because of the approximation between the odontoid process and the atlas and their biconvex articulating surfaces. Because of the lateral forces exerted by the occiput and atlas, the axis side-bends 5° to the right on C3 as a result of the inability of C1 to glide laterally on C2. The atlas will then rotate immediately to the left on the axis to maintain an anterior orientation of the face. ( 5 ) The left occipital condyle elevates as a result of the wedge-shaped lateral masses of the atlas gliding to the right. This elevation causes tension in the left alar ligament, which ( 6 ) produces compression between C2 and C1 as the axis is elevated. ( 7 ) The joint compression between the biconvex surfaces of both the atlas and the axis produces a right rotation of the axis. As lateral flexion is increased, the occiput and atlas will rotate to the left on the axis to allow anterior orientation of the face.
Rotation of the upper cervical spine ( Fig. 16-10 ) to the right begins with ( 1 ) the occiput rotating on the atlas a minute amount (approximately 1°). As joint approximation occurs, the atlas is pulled into right rotation, thereby bringing the left lateral mass of C1 closer to the dens. ( 2 ) The compressive forces that occur between the atlas and the axis produce 2° to 3° of left rotation of C2 as a result of the biconvex surfaces. ( 3 ) The occiput and atlas rotate to the right approximately 40° and apply tension on the left alar ligament, which brings the axis into right rotation. ( 4 ) The axis will continue to rotate and side-bend to the right approximately 10°, ( 5 ) which allows the occiput and atlas to rotate to the available end ROM. ( 6 ) The increased tension on the left alar ligament produces left side bending of the occiput. ( 7 ) The atlas is forced to glide to the left because of the compressive forces of the left occipital condyle. As the atlas side glides to the left, the amount of left side bending of the occiput is increased as the wedge-shaped lateral masses of the atlas tilt the occiput.
In the midcervical spine, the superior facets are oriented in a superior, posterior, and medial direction, whereas the inferior facets are oriented in an anterior, inferior, and lateral direction. As a result, during cervical rotation the contralateral inferior facet glides in a superior and medial direction, which produces lateral flexion in the same direction. Therefore, in the cervical region, rotation and lateral flexion always occur together in the same direction.
During flexion, the superior vertebral body slides and tilts anteriorly on the inferior vertebra, which causes separation of the facet joints. During extension, the superior vertebral body slides and tilts posteriorly. This motion is limited because of joint approximation and tension in the ALL. The facet joints are oriented to allow an increase in the amount of flexion and extension.
Evaluation
“The least reliable way to diagnose in soft tissue lesions is to palpate immediately for tenderness in the area outlined by the patient.”
—James Cyriax, M.D.
During evaluation of the cervical spine it is important to perform a screening examination of the thoracic spine, temporomandibular joint, and upper extremities to ensure that the pathology is cervical in nature. Box 16-1 outlines an examination flow. It is helpful to take a systemic approach to the evaluation process to ensure that no step in the assessment is overlooked and to allow a smooth, systematic flow of the examination. By performing all the aspects of the examination listed in Box 16-1 , the sports rehabilitation specialist will be able to determine which tissue or tissues are affected as a result of the tissue’s response to the test imposed. Each tissue is suspected as being a potential source of pain until that tissue has been cleared by careful examination. To clear a tissue, the clinician must perform tests that create stress or tension on that tissue. If a positive response does not occur, the tissue can be excluded as a source of pain.
Initial Observation
Posture and position of the head and cervical sprain
General demeanor of the athlete
Athlete’s Subjective History
Structural Inspection
Observe from the anterior/posterior/lateral views for alignment and position
May perform both in seated/standing postures
Observe in both habitual/corrected postures
Active Motion
The examiner notes the speed, willingness to move, range, quality of movement, and availability of segmental movement:
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Flexion
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Extension
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Lateral flexion
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Rotation
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Combined motions
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Repetitive motions
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Passive Motion
The examiner notes the end-feel, availability of movement, and restrictions:
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Flexion
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Extension
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Lateral flexion
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Rotation
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Prolonged positions
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Overpressure
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Resisted Motion
Each motion is tested in three positions (mid, inner range, outer range):
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Flexion
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Extension
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Lateral flexion
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Rotation
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Palpation
Note temperature variations, atrophy, muscle bulk, tone, swelling, tenderness, thickness, dryness, moisture, abnormalities, crepitus, and pain
Neurologic Tests
Sensation tests
Reflexes
Myotomes
Special Tests
Vascular tests:
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DeKleyn test (vertebral artery test)
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Hautant test
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Underburg test
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Neurologic tests:
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Distraction
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Compression
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Shoulder abduction test
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Valsalva maneuver
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Upper limb tension tests (ULTTs):
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ULTT1
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ULTT2
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ULTT3
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ULTT4
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Instability tests:
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Odontoid fracture
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Transverse ligament
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Thoracic outlet syndrome tests:
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Roos test
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Adson test
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Allen test
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Costoclavicular compression maneuver
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Pectoralis minor test
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Wright hyperabduction test
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Mobility Tests
Lower and midcervical spine:
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Flexion
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Extension
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Lateral flexion
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Rotation
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Upper cervical spine:
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Atlantooccipital:
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Flexion
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Extension
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Lateral flexion
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Rotation
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Atlantoaxial:
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Rotation
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Diagnostic Tests
Radiographs, magnetic resonance imaging, computed tomography, myelography, electromyography, laboratory tests
Visual Observation
The examination process begins with visual observation of the athlete. The clinician watches the athlete walk into the room and observes the positioning of the athlete’s head, neck, and shoulder girdle. The sports rehabilitation specialist may be able to detect any defects or abnormalities that are present and develop an understanding of how the pain is affecting the patient’s functional ability. The clinician may be able to ascertain the athlete’s ability, speed, and willingness to move the head and upper limbs, which can give an indication of the degree of injury present.
History
The athlete’s subjective history is an important aspect of the evaluation process. By eliciting a complete history, the clinician can obtain clues regarding the patient’s diagnosis. The rehabilitation specialist will develop a better understanding of the athlete’s condition and will gain insight into the direction and intensity of the examination and treatment needed.
It is important to allow the athlete to describe the current complaint and any previous related conditions. The athlete should be encouraged to describe the symptoms, including the location and nature of the pain, as well as any conditions that increase or relieve these symptoms. A visual analog pain-rating scale is commonly used to allow the athlete to indicate the severity of the pain. Although many different types of analog scales are available for use, it is important to use the same scale for consistency. The clinician should be aware of the athlete’s goals and the time frame for achieving these goals. This will ensure that both the clinician and the athlete clearly understand one another and will allow insight into the athlete’s motivation.
Structural Inspection
The clinician begins an inspection of the athlete in a standing position after the athlete has undressed. The visual inspection can include the patient standing in a normal, habitual stance and in the anatomic position. The clinician should briefly perform a full examination of the entire body of the patient in anterior, lateral, and posterior views while observing body contours and looking for any structural abnormalities or postural faults that may be present. The clinician can observe the athlete’s respiratory pattern to assess rate and rhythm and determine whether inspiration originates from the diaphragm or from the upper thoracic region. The clinician may also choose to perform an inspection while the patient is in both habitual and upright sitting postures. Because postural abnormalities (i.e., forward head, rounded shoulders) profoundly amplify any decreased ROM and function, the clinician should make note of such abnormalities because of their potential contribution to tissue irritation.
Active Movements
The first motions performed by the athlete are active movements. This allows the clinician to observe not only the patient’s available ROM but also the quality of motion, pain elicited, and the speed and willingness to move. The athlete begins by performing cardinal plane motions. As the patient performs the active movements, the clinician should observe for segmental areas that have either an abrupt or reduced angulation. This may indicate areas where segmental motion is altered with respect to the rest of the cervical spine.
Movements that are most painful should be performed last to ensure that the pain is not carried over during the remaining motions. If an athlete complains of pain with repetitive movements, prolonged positions (i.e., cervical flexion, extension, sitting, standing), or a combined motion, the clinician should instruct the patient to perform these actions last. In such cases it may be necessary to have the athlete repeat a movement (5 to 10 times), maintain a position (15 to 20 seconds), or perform combined movements in an attempt to reproduce the symptoms.
Passive Movements
The rehabilitation specialist performs passive ROM to assess the cervical spine for possible restrictions and to determine each motion’s end-feel. In the cervical spine, the normal end-feel for all cardinal plane movements is a tissue stretch. If ROM is restricted in multiple directions, the clinician should determine whether the limitation is in a capsular or noncapsular pattern. The capsular pattern of the cervical spine is side flexion and rotation equally limited, slight limitation of extension, and full flexion. A noncapsular pattern will have limitations in ROM, but these limitations do not resemble those in the capsular pattern. Noncapsular restriction may result from pain, adhesions, or internal derangement. During assessment of passive ROM it is important to remember that greater ROM will occur if the passive movements are assessed while the athlete is supine as opposed to when the patient is seated. This is a result of the increased muscular tone present in the seated position to maintain an erect head.
The clinician may choose to hold a movement for a sustained period or to apply overpressure at the end range. The clinician may also opt to bias the amount of overpressure on the upper or lower cervical spine to evoke symptoms. For example, overpressure into extension for the upper cervical spine ( Fig. 16-11, A ) can be performed by passively flexing the midcervical and cervicothoracic spine followed by extending the upper cervical segments. Extension overpressure on the lower cervical spine (see Fig. 16-11, B ) can be induced by flexing the upper cervical spine and then introducing extension into the lower segments. The clinician must be careful to not generally overstress the system without an appropriate differential assessment, which may require radiologic testing.
