Cervical spine mobilization and manipulation

Cervical spine mobilization and manipulation

Mobilization and manipulation
The term mobilization is usually associated with low-velocity rhythmic movements applied in short or large amplitudes, while manipulation involves high-velocity movements applied over small amplitudes.1According to Maitland spinal manipulative therapy includes techniques based on joint manipulation and mobilization, the main difference being the amplitude and velocity of the force applied to the vertebrae.1
Symptoms and treatment
In the past, randomized clinical trials and systematic reviews have shown the efficacy of techniques on pain relief and function restoration in patients with both chronic and acute non-specific neck pain.2-7Maitland et al1 suggested that the selection of mobilization techniques for patients with neck pain should depend on pain localization and symptom reproduction, and the vertebral level to be treated should be the one that most often reproduces symptoms during accessory movement testing. However, previous studies have demonstrated that applying spinal manipulative therapy to asymptomatic areas may also result in symptom improvement.8-10Studies have also shown that mechanical stimuli on spinal vertebrae produce vertebral motions not only at the segmental contact, but also in the adjacent vertebral segments in ovine14 and human15 spines. Therefore, by mobilizing any cervical vertebrae, motion would be produced in other cervical segments, one of which could be the symptomatic segment. Whether this motion propagation would be enough to be responsible for clinical improvement still has to be elucidated.

Another feasible explanation for immediate decreases in pain, in particular pain during the most symptomatic active movement, could rely on changes in muscle activity following spinal mobilization. Ferreira et al16 have previously demonstrated that joint mobilization can produce immediate significant changes in the functional activity of trunk muscles in patients with chronic low back pain. Immediate changes in muscle function could reflect either changes in motor neuron excitability following spinal mobilization or changes in the output from higher centers.16 Posterior anterior spinal mobilizations also produce decreases in EMG activity of superficial neck flexor muscle activity.1 Immediate motor changes could, therefore, result in less painful active movements following spinal mobilizations.

Among five old case series that described the effects of manipulation or mobilization on neck pain, 83 of 99 patients reported improvement (based primarily on patients reports ranging from immediately after the intervention to 2 years later), 11 of 99 reported change in symptoms, and 5 of 99 reported increased pain.17-21

Effects of mobilization and manipulation
Cleland et al observed that thoracic spine manipulation results in immediate improvements of neck pain when compared to placebo, suggesting that thoracic spine manipulation may be a reasonable alternative or perhaps a supplement to manual therapy interventions directed to the cervical spine.9 Vicenzino et al have demonstrated that a cervical contralateral lateral glide produces significant improvements in pressure pain threshold, pain-free grip strength, and pain scores in patients with lateral epicondylalgia.10Recent studies have shown that spinal manipulation can activate an endogenous, descending, pain-inhibitory system, resulting not only in manipulation-induced hypoalgesia but also in sympatho-excitation and motor effects.7,11,12,13
Clinical prediction rules (3) for cervical spine (according to Cleland, Tseng and Childs)
Cleland’s Study: Development of a clinical prediction rule for guiding treatment of a subgroup of patiënts with neck pain: use of thoracic spine manipulation, exercise and patiënt education Cleland et al. 2007Criteria:– Symptoms are present less than <30 days
– No symptoms distal to the shoulder
– No aggravation of symptoms when looking up
– FABQ <12
– Reduced thoracic kyphosis
– Cervical extension ROM <30 degrees

Number of criteria present Sensitivity Specificity % successful manipulation
6 0.05 1.00 100
5 0.12 1.00 100
4 0.33 0.97 93
3 0.76 0.86 86
2 0.93 0.56 71
1 1.00 0.17 58
Tseng’s Study: Predictors for the immediate responders to cervical manipulation in patients with neck pain Tseng et al 2005Criteria:– NDI <11,50

– Bilateral

– Less than >5 hours per day performing sitting work
– Better feeling when moving the neck
– No aggravation of symptoms when extending the neck
– Diagnosis of spondylosis without radiculopathy

Number of criteria present Sensitivity Specificity % successful manipulation
1 0.02 0.75 10
2 0.08 0.57 23
3 0.43 0.87 74
4 0.40 0.93 89
5+ 0.07 1.00 100
Childs Study: Proposal of a classification system for patients with neck pain Childs et al. 2004

Classification Examination findings Proposed matched interventions
Mobility – Recently developed symptoms

– No radicular symptoms in the upper extremity

– Limited ROM at rotation or a difference in lateral flexion
– No signs or symptoms of nerve compressions or peripheral symptoms of the upper extremity during cervical ROM

– Manipulation/mobilization of the cervical and thoracic spine

– Exercises for active ROM

Conditioning and increased tolerance aimed for exercises – Low back pain and disability scores- Recently developed symptoms

– No signs of symptoms of nerve root compression

– No peripheral symptoms / centralization in ROM

– Exercises aimed for strength and endurance of the neck and shoulder muscles

– Aerobic exercises

Reducing headache – Unilateral headache with an origin in the neck (with neck complaints)
– Headache triggered by movements or positions of the neck
– Headache that pops up at pressure on the posterior part of the neck
– Manipulation/mobilization of the cervical spine

-Strengthening of the neck and shoulder muscles

– Postural related exercises

Self-mobilization techniques for the cervical spine
Cervical Spine Rotation Self-mobilization with patient sitting

Cervical Spine Extension Self-mobilization with patient sitting

Mobilization techniques for the cervical spine
High cervical lateral flexion mobilization with patient supine

Cervical z-joint and u-joint mobilization with patient supine

Cervical uncovertebral mobilization patient sitting
Maitland techniques with patient prone

Manipulation techniques for the cervical spine
Cervical manipulation with patient supine and prone

Literature
  1. Maitland G, Hengeveld E, Banks K, English K. Maitland’s Vertebral Manipulation. 6th ed. Woburn, MA: Butterworth Heinemann; 2001.
  2. Bronfort G, Haas M, Evans R, Bouter L. Efficacy of spinal manipulation and mobilization for low back pain and neck pain: A systematic review and best evidence synthesis. Spine J. 2004;4:335-356.
  3. Childs J, Fritz J, Flynn T, et al. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: A validation study. Ann Intern Med. 2004;141:920-930.
  4. Hoving J, Koes B, de Vet H, et al. Manual therapy, physical therapy, or continued care by a general practitioner for patients with neck pain. Ann Intern Med. 2002;136:713-722.
  5. Hurwitz E, Acker P, Adams A, Meeker W, Shekelle P. Manipulation and mobilization of the cervical spine: A systematic review of the literature. Spine. 1996;21:1746-1759.
  6. Hurwitz E, Morgenstern H, Harber F, et al. A randomized trial of chiropractic manipulation and mobilization for patients with neck pain: Clinical outcomes from the UCLA neck pain study. Am J Public Health. 2002;92:1634-1641.
  7. Korthals-de Bos I, Hoving J, van Tulder M, et al. Cost-effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: Economic evaluation alongside a randomized controlled trial. BMJ. 2003;326:911-917.
  8. Chiradejnant A, Maher C, Latimer J, Stepkovitch N. Efficacy of “therapist-selected” versus “randomly selected” mobilization techniques for the treatment of low back pain: A randomized controlled trial. Aust J Physiother. 2003;49:233-241.
  9. Cleland J, Childs M, Mcrae M, Palmer J, Stowell T. Immediate effects of thoracic manipulation in patients with neck pain: A randomized clinical trial. Man Ther. 2005;10:127-135.
  10. Vicenzino B, Collins D, Wright A. The initial effects of a cervical spine manipulative physiotherapy treatment on the pain and dysfunction of lateral epicondylalgia. Pain. 1996;68:69-74.
  11. Sterling M, Jull G, Wright AMT. Cervical mobilisation: Concurrent effects on pain, sympathetic nervous system activity and motor activity. Man Ther. 2001;6:72-81.
  12. Mclean S, Naish R, Lloyd R, Urry S, Vicenzino B. A pilot study of the manual force levels required to produce manipulationinduced hypoalgesia. Clin Biochem. 2002;17:304-308.
  13. Mcneely M, Armijo S, Magee D. A systematic review of the effectiveness of physical therapy interventions for temporomandibular disorders. Phys Ther. 2006;86:710-725.
  14. Colloca CJ, Keller TS, Harrison DE, et al. Spinal manipulation force and duration affect vertebral movement and neuromuscular responses. Clin Biochem. 2006;21:254-262.
  15. Kulig K, Landel R, Powers CM, et al. Assessment of lumbar spine kinematics using dynamic MRI: A proposed mechanism of sagittal plane motion induced by manual posterior-to-anterior mobilization. J Orthop Sports Phys Ther. 2004;34:57-64.
  16. Ferreira M, Ferreira P, Hodges P. Changes in postural activity of the trunk muscles following spinal manipulative therapy. Man Ther. 2007;12:240-248.
  17. Bael MC, Vorro J, Jognston WL. Chronic cervical dysfunction: correlation of myoelectric findings with clinical progress. J Am Osteopath Assoc 1989;90:891-900.
  18. Cassidy JD, Quon JA, LaFrance LJ, Yong-Hing K. The effect of manipulation on pain and range of motion in the cervical spine: A pilot study. J Manip Physiol Ther 1992;15:495-500.
  19. Graff-Radford SB, Reeves JL, Jaeger B. Manangement of chronic head and neck pain: Effectiveness of altering factors perpetuating myofascial pain. Headache 1987;27:186-90.
  20. Livingston M. Spinal manipulation: A one year follow-up study. Can Fam Physician 1969;15:35-9.
  21. Menell JM. The validation of the diagnosis “joint dysfunction” in the synovial joints of the cervical spine. J Manip Physiol Therp 1990;13:7-12.

 

Leave a Reply