Cervical Region: Considerations for HVLA

1
Cervical Region Considerations for HVLA
Pernkopf, Vol I, p. 296
2
1 of 2

• Ground Rules for todays session
• If you have not had an introduction to HVLA, you
  will not be performing cervical HVLA today.
• If your partner does not give his/her consent for
  HVLA for a diagnosed dysfunction in his/her neck,
  you will not be performing HVLA on that
  individual.

3
2 of 2

• Ground Rules for todays session
• However, you will get experience in localizing
  forces to a dysfunctional cervical segment
• Then using Incremental Mobilization or Muscle
  Energy treatment
• Which can ultimately be preparatory for HVLA.

4
Clinical

• Etiology of cervical somatic dysfunction
• Postural imbalance
• Tightness prone/weakness prone
• Traumatic cranial somatic dysfunction
• Cervical trauma- whiplash
• Chronic inflammatory conditions
• Repetative injury
• EENT pathology
• Visceral-C2 -vagus
• Diaphragm-C3-5- phrenic
• Superior Thoracic Aperture Dysfunction
• Sacro-pelvic dysfunction

5
Clinical Syndromes

• Cervicocephalic-Pain and motion restriction upper
  C-spine and associated superficial and deep pain
  in head
• Visual changes, vertigo, dizziness, nystagmus
• Cervical-Painful stiffness of neck
• Mild to acute spastic torticollis
• Cervicobrachial-Painful stiffness C-spine with
  symptoms in shoulder girdle and upper extremity
• Upper Extremity-brachial plexus, arterial,
  venous, lymphatic
• Thoracic Inlet-1st 2nd ribs, T-spine, ribs, T5-6

6
American Osteopathic Association Position Paper
On Osteopathic Treatment of the Cervical Spine

• Conclusion
• it is the position of the AOA that all
  modalities of osteopathic manipulative treatment
  of the cervical spine, including HVLA, should be
  taught at all levels of education, and that
  osteopathic physicians should continue to offer
  this form of treatment.

Adopted by the AOA House of Delegates, July 17,
2004
7
Benefits

• Vagus nerve visceral component
• Phrenic nerve diaphragm
• Vertebral artery
• Lymphatic drainage
• Head region dysfunction

8
Complications

• RARE
• Usually reported in connection with HVLA
• Neurovascular accidents
• Aggravation of disc problem
• Fractures
• Vertigo
• Reasons
• Lack of skill
• Diagnostic error
• Inappropriate use of force
• Avoiding Complications
• Avoid overextension
• Diagnose accurately
• Dont force beyond tolerance
• Re-evaluate diagnosis and treatment method

9
Contraindications

• Muscle Energy
• Low vitality
• Unable to follow commands
• Mobilization with Impulse
• Absolute
• Osteoporosis/Osteomyelitis/Fracture
• Rheumatoid Arthritis/Downs
• Weakness transverse ligament
• Relative
• Acute Whiplash
• Pregnancy
• Post OP
• Herniated Nucleus Propulsus
• Anticoagulants
• Vertebral Artery Ischemia

10
Anatomic Considerations for Cervical Treatment
11
Autonomics

• Superior cervical ganglion
• Sympathetic control cervical blood flow
• Bound by deep connective fascia
• Cervical nerves 1-8
• Exit above the vertbra for which they are named
  Except CN8, which leaves the spinal canal below
  C7
• C2-Small branch connects to Vagus
• Internal visceral disease
• C3-5-Phrenic
• Diaphragm Dysfunction
• Brachial and cervical plexuses
• Mechanoreceptors/Nociceptors/Muscle spindles
• Postural proprioceptors

12
Cervical Anatomy

• It is the one to two segment muscles, in
  particular, (along with the function of the
  zygapophyseal joint and the capsular structures)
  we wish to influence with articular dysfunction
  in the cervical spine

Hollingshead, p.136
13
Deep muscles posterior

• Rectus capitis posterior major
• Rectus capitis posterior minor
• Obliquus capitis superior
• Obliquus capitis inferior
• Interspinalis
• Intertransversii

Notice that these muscles controlling the
individual motions in the cervical spine are
small and short.
14
Deep muscles anterior

• Obliquus caqpitis superior
• Obliquus capitis inferior
• Longus colli
• Rectus capitis lateralis
• Rectus capitis anterior

15
Intermediate muscles
Multi-Joint Muscles If these Muscles are
Tight/Tender, Some of the Regional Stretches May
Prepare the Patient for Local Treatment
16
Superficial Muscles
Multi-Joint Muscles If these Muscles are
Tight/Tender, Some of the Regional Stretches May
Also Prepare the Patient for Local Treatment
17
These muscles are often forgotten.
18
Cervical Review

• Facet surfaces always in contact unless traction
  applied
• No physiologic neutral facets not engaged
• Movement determined by plane and contour of facet
  surfaces

19

• Articular pillars
• With Superior Facets facing Backward Upward and
  Medial Rotation Requires Sidebending to the Same
  Side (and Visa Versa)

CIBA, vol. 8, part 1, p.10
20
Determinates of Motion

• Joint configuration and intervertebral disc
• Allow movement in all directions
• Load bearing
• Facing of zygapophysial joints
• Plane and contour of facet surfaces
• Characteristics of vertebral bodies and discs
• Fryettes Third Principle
• Initiation of motion of a vertebral segment in
  any plane of motion will modify the movement of
  that segment in other planes of motion

21
Uncovertebral Joints-Joints Of Luschka

• Posterolateral corner vertebral bodies
• Function in gliding movements/limit lateral
  translation

Cailliet, Functional Anatomy of the
Musculoskeletal System
22
Cailliet, Functional Anatomy of the
Musculoskeletal System, p. 99
23
1 of 2

• Planes of facets not parallel
• Meet near tip of SP of C7
• Angles of planes increase upward
• 10-60 degrees-avg. incline of 45 degrees

CIBA, Vol. 8, p. 11
24
C2-7

• Facet joints support 1/3 weight of head
• Bodies articulate through intervertebral disc and
  synovial joints
• Unless traction applied- no pure rotation or
  sidebending
• Sidebending and rotation occur to same side

25
C2-7

• Flexion
• Inferior facet slides superior and anterior on
  superior facet of vertebra below
• Anterior translation of body
• Extension
• Inferior facet slides inferior and posterior on
  superior facet below
• Posterior translation of body
• A-P lordotic curve

26
Palpatory Exercise

• Feel the motion of the facets contacting your own
  neck with fingers on several consecutive levels.
• Cervical Flexion
• Feel how the facet of the superior vertebra lifts
  superior and forward
• Cervical Extension
• Feel how the facet of the superior vertebra drops
  inferior and posterior

27
Clinical

• Etiology of cervical somatic dysfunction
• Postural imbalance
• Tightness prone/weakness prone
• Traumatic cranial somatic dysfunction
• Cervical trauma- whiplash
• Chronic inflammatory conditions
• Repetative injury
• EENT pathology
• Visceral-C2 -vagus
• Diaphragm-C3-5- phrenic
• Superior Thoracic Aperture Dysfunction
• Sacro-pelvic dysfunction

28

• Cervical treatment is not necessarily the first
  step for a cervical complaint.
• Superior Thoracic Aperture Dysfunction may be
  part of the source of cervical complaints
• Thoracic
• Upper Rib
• Upper Extremity should be evaluated
• Sacral Dysfunction may also contribute

29
Diagnosis Lateral Translation

• Test for SB mobility
• Passively move superior vertebrae
• Translation Opposite SB
• Flexion- translation resistance-impaired joint
  opposite side of SB resistance
• Extension- translation resistance- impaired joint
  on same side of SB resistance

30
Lateral Translation Test

• Patient supine
• Physician seated at head of table
• Support occiput on palms
• Place index fingers on C2 to start
• Finger pads contact articular pillars
• Maintain the neck without introducing flexion or
  extention

31

• Planes visualized with spine in the supine
  position

• Fingerpad contact on the lateral aspect of the
  articular pillar

CIBA, Vol. 8, p. 11
32
Lateral Translation for Sidebending Mobility
0

• Translate L and R
• Passively move superior vertebrae
• By pushing the vertebra with each finger pad
  contact sequentially
• Monitor distance-
• compare sides
• Repeat in flexion
• and extension
• may use proximal
• phalanges for ext.
• Repeat at each
• cervical level

Mitchell, ME Manual Vol.1
33
Lateral Translation Test Results

• Equal ROM no restriction or b/l rest.
• Rare both restricted
• FRSR or FRSL
• ERSR or ERSL

For Optimal Treatment of these two, it is
important to determine which facet joint is stuck.
34
Why is the knowledge of which facet joint is
stuck important?

• For the purposes of treatment it helps the
  physician interpret the resistance felt.
• This helps the localization process and setting
  up the vector for the activating force.
• For Incremental Mobilization, this provides a
  better focus of attention for the response to the
  palpating fingers movement input.
• For HVLA, this means less force is required when
  the thrust is performed.

35
Which facet joint is restricted?

• C2-7 Lateral Translation Test Translation
  Resistance Left or Right with the Head in Flexion
  or Extension gt Diagnosis (FSleftRright,
  ESleftRright, etc.)
• Example C4 ERSR (ERSright)
• See next slide.

36
Step 1 Make your Diagnosis

• Resists Translation from the left toward the
  right while the head is flexed.
• Therefore it resists Left sidebending
• Which tells the position of ease for the
  diagnosis Sidebent Right
• Sidebent Right at the C2-7 requires Rotation
  Right.

Adapted from Mitchell, Vol. I, p.195

• Therefore the diagnosis is C4 ERSR (ERSright)

37
Which facet joint is restricted?

• Which direction do the facets of the superior
  vertebra have to go with the head/neck
  positioned into the resistance (restriction)?
  Superior-Anterior or Inferior-Posterior
• Example continued C4 ERSR (ERSright)
• See next slide.

38
Step 2 Direction of Facet Motion with Head in
Position of Translation Resistance
Adapted from Mitchell, Vol. I, p.195

• Example Diagnosis C4 ERSR (ERSright)
• Flexion is the Head/Neck Position in which
  Translation Resistance Was Encountered at C4.

• Facets of the superior vertebra have to go
  superior-anterior

39
Which facet joint is restricted?

• Use the diagnosed direction of rotation to
  determine which facet of the superior vertebra
  must move to create that motion.
• Example continued C4 ERSR (ERSright)
• See next slide.

40
Step 3 Direction of Facet Motion with Head in
Position of Translation Resistance
Adapted from Mitchell, Vol. I, p.195

• Example Diagnosis C4 ERSR (ERSright)
• According to the Diagnosis C4 rotates Right
• Which Facet of the Superior Vertebra Must Move
  For This To Happen?
• In Head/Neck Flexed Position the facets of the
  superior vertebra are moving Anterior.
• The Left Facet must move anterior for Right
  Rotation to occur.

• Therefore, the Right facet joint is the
  restricted joint. It is stuck inferior-posterior.

41
Which facet joint is restricted?

• C2-7 Lateral Translation Test Translation
  Resistance Left or Right with the Head in Flexion
  or Extension gt Diagnosis (FSleftRright,
  ESleftRright, etc.)
• Which direction do the facets of the superior
  vertebra have to go with the head positioned
  into the resistance (restriction)?
  Superior-Anterior or Inferior-Posterior
• Use the diagnosed direction of rotation to
  determine which facet of the superior vertebra
  must move to create that motion.

42
Lateral Translation Test Results

• Restriction with Extension
• Facet joint stuck on same side as translation
  resistance
• Will not translate right/sidebend left when
  extended.

X
FRSR
Mitchell, Vol. I, p.195
43
Lateral Translation Test Results

• Restriction with Flexion
• Facet joint stuck on opposite side as restricted
  translation- cant glide anterior
• Will not translate right/sidebend left when
  flexed.

X
ERSR
Mitchell, Vol. I, p.195
44
Test with Head Neck Flexed

• If cannot translate vertebra L, then
• Diagnosis- ERSleft
• Cannot sidebend R
• L facet cannot slide forward, so rotation L
  occurs
• L facet posterior
• Free movements
• Extension,Left sidebending rotation

• If cannot translate vertebra R, then
• Diagnosis- ERSright
• Cannot sidebend L
• R facet cannot slide forward, so rotation R
  occurs
• R facet posterior
• Free movements
• Extension, Right sidebending rotation

45
Test with Head Neck Extended

• If cannot translate vertebra L, then
• Diagnosis- FRSleft
• Cannot sidebend R
• R facet cannot slide backward, so L rotation
  occurs
• R facet anterior
• Free movements
• Flexion,Left sidebending rotation

• If cannot translate vertebra R, then
• Diagnosis- FRSright
• Cannot sidebend L
• L facet cannot slide backward, so R rotation
  occurs
• L facet anterior
• Free movements
• Flexion, Right sidebending rotation

46
Implications for Treatment

• FRSR Rotational Activating forces need to be
  directed toward the left facet and articular
  pillar from a right sided contact.
• Rotational Force Directed Toward the Facet
  Opposite the Sidebending Preference
• Side Bending Force
• The left facet joint needs to be closed.

MCP
FRSR
Mitchell, Vol. I, p.195
47
Implications for Treatment

• FRSR Side Bending Activating forces need to be
  directed toward the left facet and articular
  pillar from a left sided contact.
• Side Bending Force Directed Toward the Facet
  Opposite the Sidebending Preference
• The left facet joint needs to be closed. You are
  pushing the bottom facet back under the top
  facet.

MCP
FRSR
Mitchell, Vol. I, p.195
48
Implications for Treatment

• ERSR Rotational Activating forces need to be
  directed toward the right facet and articular
  pillar
• Rotational Force Directed Toward the Facet On
  the Same Side As the Sidebending Preference
• The right facet joint needs to be opened.

MCP
ERSR
Mitchell, Vol. I, p.195
49
Implications for Treatment

• ERSR Side Bending Activating forces need to be
  directed toward the right facet and articular
  pillar from a left sided contact.
• Side Bending Force Directed Toward the Facet On
  the Same Side As the Sidebending Preference from
  the Opposite Side

MCP
ERSR

• The right facet joint needs to be opened.

Mitchell, Vol. I, p.195
50
Lateral Translation Test Results

• Restriction with Extension
• Facet joint stuck on same side as translation
  resistance
• Will not translate right/sidebend left when
  extended.

X
FRSR
51
Lateral Translation Test Results

• Restriction with Flexion
• Facet joint stuck on opposite side as restricted
  translation- cant glide anterior
• Will not translate right/sidebend left when
  flexed.

X
ERSR
52
TREATMENT
53
Incremental Mobilization I

• Use the cephalad hand to gently cup the occiput
• Cervical spine held in neutral
• Use the thumb and index (or middle finger) to
  contact the articular pillars starting at C2
• Cephalad Hand add cephalad traction down into
  the dysfunctional segments facet articulations
  (to disengage the facets)

54
Incremental Mobilization I

• Caudad Hand introduce rhythmic translatory
  motion left and right
• Visualize the angle of the plane of the facets at
  that level
• Visualize the vector of force going through the
  plane of the facets.
• Visualize the activating force going into the
  stuck facet joint
• Repeat with cervical spine flexed, then extended
• Repeat with C3, C4, etc.

55

• Planes visualized with spine in the supine
  position

• Fingerpad contact on the lateral aspect of the
  articular pillar

CIBA, Vol. 8, p. 11
56
HVLA (Mobilization with Impulse)

• Progress through the steps of preparation and
  localization.
• Have an instructor confirm your localization
• If your patient and instructor agree, proceed
  with mobilization
• If you have not used HVLA before, use only
  incremental mobilization.

57
Preparation for HVLA in the Cervical Region

• Regional Soft tissue
• Indirect Techniques
• Muscle Energy
• Incremental Mobilization
• One or several may be necessary or may be
  desirable.
• Use of these will allow easier localization and a
  lesser activating force.

58
Contact for HVLA

• The Metacarpophalangeal joint/proximal phalanx of
  the index finger is used to contact
• AA, C2-7 the vertebra of interest
• OA the occiput

59
Direction of Force

• C2-7
• C2-4 Rotary impulse
• C4-7 Side Bending impulse
• AA Rotary impulse
• OA Impulse directed toward the opposite orbit
• The forearm elbow are lined up with the
  direction of force (like the shaft of the arrow,
  pointing in the direction of the thrust).

60
HVLA Principles

• Check your body position/comfort.
• Engage the resistance gently.
• It should feel like the tension is focused in an
  area no larger than the size of a nickel. If
  that is not the case
• Get further patient relaxation.
• More soft tissue preparation?
• Recheck diagnosis
• Refine the localization.
• Thrust.
• Recheck.

61
Patient Relaxation

• Patients rarely relax fully before a thrust in
  the cervicals.
• Localize approximately, then
• Instructions that are helpful
• Ask the patient to take a deep breath in, then
  slowly let it out.
• As the patient lets the breath out ask him/her to
  let the head and neck drop toward the table
• Fine Tune the localization, then thrust (Low
  Amplitude quick, but gentle.

62
Patient Relaxation

• During the patients relaxation response it is
  helpful to dance up to the localized barrier
  and dance back from it.
• Find the barrier, but dont stay on it.
• You now know where it will be found with the next
  relaxation cycle.
• With the next relaxation breath and head release
  toward the table the thrust can then be done with
  more precision

63
Patient Relaxation

• It may be helpful for localization to have the
  patient nod the chin or raise the chin just a
  little.
• This can improve patient relaxation.
• It can help focus localization so that less
  activating force is necessary.

64
Unsuccessful Correction of Somatic Dysfunction in
the Cervical Region

• Practitioner Error
• Wrong Diagnosis
• Insufficiently localized
• Insufficient tissue preparation
• Inappropriate force
• Inter-regional Considerations
• Superior thoracic aperture dysfunction (S.D.) may
  be primary
• Thoracic S.D. may be primary
• Upper Extremity tensions dysfunction may be
  influencing the area
• Upper cervical segments can be influenced by
  sacral dysfunction or cranial base dysfunction.

65
SUMMARY
66
References

• Mitchell, Jr. Fred L. The Muscle Energy Manual,
  Volume One. East Lansing, Michigan MET Press
  1995 pp158-201

67
References

• Greenman P. Principles of Manual Medicine. 3rd
  ed. Philadelphia Lippincott Williams Wilkins
  2003 195-199, 202-223.
• Mitchell F. The Muscle Energy Manual, Vol. 1.
  East Lansing, MI MET Press 1995 143-153,
  192-211.
• DiGiovanna E, Schiowitz S, Dowling D. An
  Osteopathic Approach to Diagnosis and Treatment.
  3rd ed. Philadelphia Lippincott-Raven
  Publishers 2005 127-128, 138-139,169-172.
• Kimberly P. Outline of Osteopathic Manipulative
  Procedures The Kimberly Manual. Millennium ed.
  Marceline Walsworth Publishing Co 2000 37-40,
  73-80.
• Cailliet R. The Illustrated Guide to Functional
  Anatomy of the Musculoskeletal System. AMA Press
  2004 85-111.

68
American Osteophathic Association Position Paper
On Osteopathic Treatment of the Cervical Spine
1 of 9

• Conclusion
• Therefore, it is the position of the AOA that
  all modalities of osteopathic manipulative
  treatment of the cervical spine, including HVLA,
  should be taught at all levels of education, and
  that osteopathic physicians should continue to
  offer this form of treatment.

Adopted by the AOA House of Delegates, July 17,
2004
69
AOA Position Paper- Cervical Spine Treatment
2 of 9

• Acknowledged Benefits
• Relief of acute neck pain
• Reduction of subacute or chronic neck pain
• Short-term relief of tension headache
• Relief of cervicogenic headache
• Relief of acute migraine symptoms

70
AOA Position Paper- Cervical Spine Treatment
3 of 9

• Potential Harm
• Neck strain
• Estimated Risk of Major Impairment Following
  Cervical Spine Manipulation 6.39 per 10 Million
  (est. 33 million manip/yr)
• Cervical disc herniation
• Vertebrobasilar accident

71
AOA Position Paper- Cervical Spine Treatment
4 of 9

• Potential Harm
• Vertebrobasilar accident
• Spontaneous occurrence nearly twice the risk from
  cervical manipulation

72
AOA Position Paper- Cervical Spine Treatment
5 of 9

• Comparison with Alternative Treatments
• NSAIDS 2500 deaths per year d/t GI
  complications 15th most common cause of death
• Epidural Steroid Injections .6-10 complication
  rate

73
AOA Position Paper- Cervical Spine Treatment
6 of 9

• Provacative Tests
• Unreliable for demonstrating reproducibility of
  ischemia or risk of injuring the vertebral
  artery.

74
AOA Position Paper- Cervical Spine Treatment
7 of 9

• Risk Factors
• Most Common Risk Factors for VBA
• Migraine
• Hypertension
• Oral Contraceptives
• Smoking

75
AOA Position Paper- Cervical Spine Treatment
8 of 9

• Risk Factors
• Cervical Extension has not proven to be a
  prominent risk factor, as previously
  hypothesized.
• It is still important to minimize extension
  elements in treatment.
• See next slide

76
Vertebral Artery
9 of 9

• Risk at acute angulation at C6-7
• Changes at intertransverse foramen C7-1
• OA junction changes
• Can narrow 90 on contralateral side with
  rotation
• Caution- Down syndrome, RA, agenesis odontoid
  process, fx odontoid, congenital asymmetry,
  atresia

77
Vertebral Artery

• Foraminal passage for the vertebral artery is
  decreased by as much as 35 when the cervical
  column is extended
• Avoid overextension when palpating, diagnosing
  and manipulating the cervical spine

78
Articulation of the Cervical Spine

• Figure of 8 Articulatory Technique
• Kimberly, Paul E. Outline of Osteopathic
  Manipulative ProceduresThe Kimberly Manual.
  Millennium ed. Marceline Walsworth Publishing
  Company 2000 p 73-74