1. Cervical Techniques

2. Know the following things about the Cervical spine and upper extremities
DTR’s
Sensory
Motor

3. Deep Tendon Reflexes
There are three basic deep tendon reflexes, which evaluate the integrity of the C5, C6 and C7 nerve supply. These are known as the biceps reflex, the Brachioradialis reflex, and the triceps reflex. BICEPS REFLEX – C5 Although there are multiple innervations to the biceps via C5 and C6, primary innervation is associated with C5. BRACHIORADIALIS REFLEX – C6 Although there are multiple innervations to the Brachioradialis via C5 and C6, primary innervation is associated with C6. TRICEPS REFLEX – C7 The triceps muscle is innervated by the radial nerve primarily C7.
Deep tendon reflexes are considered a lower motor reflex. Here the signal translates to the posterior horn of the spinal cord, thought internuncial neurons into the anterior horn cells and returning through the peripheral nerves to the musculature.

4. Sensory Know your dermatome C5: lateral arm C6: radial forearm, thumb
C7: long finger
C8: small finger
T1: ulnar forearm, medial aspect of elbow

5. Motor Compare strength testing from each upper extremities
Have them push against your resistance
You let them win

6. Manual Muscle Testing- Biceps
The patient’s elbow is flexed to 90 degrees and forearm is placed in supination with the palm facing up.
The examiner places one hand under elbow for stabilization and the other hand at the distal forearm to resist movement. Instruct the patient to flex the forearm.

7. Manual Muscle Testing- Triceps
The patient’s arm is abducted to 90 degrees and the elbow is flexed to 90 degrees.
The examiner places one hand under the elbow joint for stabilization and the other hand at the distal forearm to resist the movement. Instruct the patient to extend the forearm.
Triceps: The patient’s arm is abducted to 90 degrees and the elbow is flexed to 90 degrees. The examiner places one hand under the elbow joint for stabilization and the other hand at the distal forearm to resist the movement. Instruct the patient to extend the forearm.
Biceps: The patient’s elbow is flexed to 90 degrees and forearm is placed in supination with the palm facing up. The examiner places one hand under elbow for stabilization and the other hand at the distal forearm to resist movement. Instruct the patient to flex the forearm.
Brachialis: The patient’s elbow is flexed to 90 degrees and forearm is placed in pronation with the palm facing down. The examiner places one hand under elbow for stabilization and the other hand at the distal forearm. Instruct the patient to flex the forearm.
Brachioradialis: The patient’s elbow is flexed to 90 degrees and forearm is placed in neutral with the palm facing medially. The examiner places one hand under elbow for stabilization and the other hand at the distal forearm. Instruct the patient to flex the forearm.
Anterior/Flexor Forearm Compartment: The patient’s elbow is flexed to 90 degrees and forearm is placed in supination with the wrist neutral and palm facing up. The examiner places one hand under the proximal forearm for stabilization and the other hand over the patient’s hand to resist movement. Instruct the patient to flex the wrist.
Posterior/Extensor Forearm Compartment: The patient’s elbow is flexed to 90 degrees and forearm is placed in supination with the wrist neutral and palm facing up. The examiner places one hand under the proximal forearm for stabilization and the other hand over the patient’s hand to resist movement. Instruct the patient to extend the wrist.

8. Manual Muscle Testing- Flexor Compartment
The patient’s elbow is flexed to 90 degrees and forearm is placed in supination with the wrist neutral and palm up.
The examiner places one hand under the proximal forearm for stabilization and the other hand over the patient’s hand to resist movement. Instruct the patient to flex the wrist.

9. Manual Muscle Testing- Extensor Compartment
The patient’s elbow is flexed to 90 degrees and forearm is placed in supination with the wrist neutral and palm up.
The examiner places one hand under the proximal forearm for stabilization and the other hand over the patient’s hand to resist movement. Instruct the patient to extend the wrist.
Posterior/Extensor Forearm Compartment: The patient’s elbow is flexed to 90 degrees and forearm is placed in supination with the wrist neutral and palm facing up. The examiner places one hand under the proximal forearm for stabilization and the other hand over the patient’s hand to resist movement. Instruct the patient to extend the wrist.

10. Know the following Special Tests
Vascular Testing:
Carotid Bruits
Thoracic Outlet Syndrome (TOS)
Adson’s
Costoclavicular (“military”)
Hyperabduction (“Wright’s”)
Elevated Arms (“Roo’s”)
Vertebrobasilar insufficiency (“underburg”)
Allen’s
Spurling’s
Lhermitte’s
Tinel’s
Phalen’s

11. Spurling’s Test Region of Body you are testing
Cervical/neck
What you are testing for
Cervical radiculopathy
How to do it
3 Stages: The examiner passively hyperextends and laterally flexes the patient’s neck toward the involved side
What a + sign means
pain/parasthesias radiating from shoulder to the elbow ipsilateral to side of rotation (reproduction of pt’s symptoms). It could also originate pain from the trapezius and levator scapulae
Special Notes
Use Axial Compression (Modified Spurling’s – no compression).
Has low sensitivity but high specificity (can rule cervical radiculopathy out but not confirm it)
If the patient feels better, think anterior/middle scalene issue

12. Lhermitte’s Test Region of Body you are testing
Cervical/Neck
What you are testing for
multiple sclerosis or large disc herniation
How to do it
Need hips and head flexed, so Pt is in the long sitting position with Flexion of cervical spine
What a + sign means
Electric shock or lightening-like paresthesias or dysthesias in the hands or legs upon cervical flexions
Special Notes
a.k.a. Barber’s chair phenomenon
Know other indications are:
the “Barber Chair” phenomenon
Trauma to cervical spinal cord
Space occupying lesion (tumor, disc)
Multiple sclerosis
Cervical spondylosis
Vitamin B12 deficiency

13. Tinel’s Test Region of Body you are testing What you are testing for
Thumb/hand
What you are testing for
Median Nerve
How to do it
Tap over the median nerve
What a + sign means
Numbness
Special Notes
numbness in distribution of median n. (test for carpal tunnel)

14. Phalen’s Test Region of Body you are testing What you are testing for
Thumb/hand
What you are testing for
Median Nerve
How to do it
hold wrist in flexion for 60 sec, median n compression
What a + sign means
Numbness
Special Notes
numbness in distribution of median n. (test for carpal tunnel)

15. Adson’s Test - TOC Region of Body you are testing
cervical vascular
What you are testing for
TOS – Thoracic outlet syndrome
How to do it
With the patient in a sitting position, hands resting on thighs, the examiner palpates (feels) both radial pulses as the patient rapidly fills the lungs by deep inspiration and, with breath held, hyperextends the neck and turns the head toward the 'affected' side.
What a + sign means
If the radial pulse on that side is decidedly or completely obliterated, the result is considered positive. (need to hold for 10 – 15 sec)
Special Notes
Be sure you feel the pulse on the “affected” side, and that you turn the head towards the ipsilateral side you are testing

16. Costoclavicular (“military”) test - TOC
Region of Body you are testing
Vascular
What you are testing for
Thoracic Outlet Syndrome
How to do it
Pt should be seated. The shoulders are drawn downward and backward. This maneuver narrows the costoclavicular space by approximating the clavicle to the first rib and thus tends to compress the neurovascular bundle.
What a + sign means
Changes in the radial pulse with production of symptoms indicate compression.

17. Hyperabduction (Wright’s) test – TOC
Region of Body you are testing
Vascular
What you are testing for
Thoracic Outlet Syndrome
How to do it
Pt should be supine. When the arm is hyperabducted to 180 degrees, the components of the neurovascular bundle are pulled around the pectoralis minor tendon, the coracoid process, and the head of the humerus.
What a + sign means
If the radial pulse is decreased, compression should be suspected.

18. Elevated arms (Roo’s) test – TOC
Region of Body you are testing
Vascular
What you are testing for
Thoracic Outlet Syndrome (HIGHLY sensitive)
How to do it
Pt standing, and Both arms are placed at right angles to the shoulder and the forearms are at right angles to the upper arms. Both hands are opened and closed as fast as possible to see if symptoms occur. Do for 3 min
What a + sign means
Tingling, numbness will occur, but wait full 3 min
Know this is highly sensitive for TOS!

19. Vertebrobasilar Insufficiency (Underburg/ Wallenburg) Test
Region of Body you are testing
Vascular
What you are testing for
Vertebral artery insufficiency
How to do it
Have the pt lay supine, and you extend and SB the neck, and wait 30 sec
What a + sign means
Dizziness, fainting, vertigo, N/V, lightheadedness, blurred vision, and nystagmus (fast eye twitching) are all considered positive indicators of reduced/blocked blood flow.
Special Notes
+ test indicates vertebral a. insufficiency on the ipsilateral side you are testing

20. Allen’s Test Region of Body you are testing What you are testing for
vascular in hand
What you are testing for
radial/ulnar artery insufficiency
How to do it
Pt rapidly open and close fist then hold it closed. Examiner will occlude ulnar and radial artery. Instruct the pt to open fist and examiner should release one artery--look for pink repeat for opposite artery
What a + sign means
Poor return of color
Special Notes
test for Carpal Tunnel Syndrome as well

21. Examination of the Cervical Spine
Range of Motion (passive and active)
Flexion/Extension
OA Motion: Flexion/Extension
Rotation
Side bending
Segmental Diagnosis OA AA
C2 – C7 = Typical Cervicals

22. Range of motion Testing
Range of Motion (passive and active)
Flexion/Extension
OA Motion: Flexion/Extension
Rotation
Side bending
Cervical Motion Test (Passive)
FB and BB (approx 90 each direction)
Test motions in superior and inferior division.
Positive test  lost motion (<90 ).
 Must determine if loss is in superior or inferior division.
1. “Tuck Chin”  FB (45 ) OA motion
2. “Untuck Chin”  BB (45 )
Rotation (90 each direction)
50% occurs at AA joint, 50% rest of C-spine
Should be able to bring chin to shoulder
approx. 90 degrees each directions
Tests both superior and inferior division
 Must determine if loss is superior or inferior division (Best done with patient supine).
You could have some motion loss in both
Sidebending
45 degrees each direction

23. Segmental Diagnosis OA  Flexion and Extension SxRy AA  Rotation
AA  Rotation
C2 – C7 = Typical Cervicals  SxRx

24. Summary

25. Cervical Soft Tissue Forward bending stretching
Longitudinal stretching
Kneading
Trapezius stretching

26. Forward bending stretching
Objective: Stretch posterior cervical tissues
1) doctor at head of table; patient supine.
Cross forearms and place them behind pt’s head with fingertips on pt’s shoulders.
Exert slow forward bending stretch until a restrictive barrier is engaged, slowly increase to next barrier

27. Longitudinal Stretching
Objective: Relax the paravertebral muscles (PVM).
1) doctor at head of table; patient supine.
2) palmar surfaces of fingers of both hands under the neck near spinous processes
3) lift PVM with fingers and draw it toward you (cephalad = toward head)
4) release and carry tissue away from you (caudally = toward tail)

28. Kneading Objective: Relax the cervical paravertebral muscles (PVM).
1) doctor standing on patient’s side; patient supine.
2) With caudad hand, reach across patient and cup PVM; Place cephalad hand on pt’s forehead
4) Push head away from you, then pull up and laterally on PVM tissue letting head roll back toward you.

29. Trapezius Stretch Objective: Relax the trapezius muscle
1) Patient supine, doctor at head of table
2) Stabilize one shoulder with opposite hand
3) With free hand contact same side of head as stabilized shoulder and introduce GENTLE stretch

30. ME for Cervical Spine
C2 – C3 supine direct ME (isometric) Kimberly manual A-3, pg 79

31. Supine-Direct-ME C3 RLSL
Reach under spine to contact the convex side.
Pull with fingers to induce Right Sidebending (reverse the curve)

32. Supine-Direct-ME C3 RLSL
Place counterforce on LEFT side of patients head
Direct patient through 3-4 cycles of Muscle energy.
Note:
Readjust in SMALL INCREMENTS with finger on C-spine

33. HVLA for Cervical Spine
C2 – C3
Supine – Direct Method – HVLA Rotation emphasis, Kimberly manual, A-1, pg 78
Supine – Direct Method – HVLA sidebending emphasis, Kimberly manual, A-2, pg 79
C4 – C7
Supine – Direct Method – HVLA, Kimberly manual, B-1, pg 81

34. For C2 – C3: Supine – Direct Method – HVLA Rotation emphasis, Kimberly manual, pg 78
Backward Bend
Rotate into the barrier
Sidebend away from barrier (slightly)
HVLA Rotation Thrust

35. Supine-Direct-HVLA Rot Emphasis C3 RLSL
Bilateral contact at articular pillars at inferior portion of C3

36. Supine-Direct-HVLA Rot Emphasis C3 RLSL
Backward Bend at C3/C4 joint by lifting anterior
Do not hyperextend entire cervical spine, only the ONE segment.

37. Supine-Direct-HVLA Rot Emphasis C3 RLSL
Maintain tight contact at Left articular pillar!!
Rotate to the Right to the restrictive barrier

38. Supine-Direct-HVLA Rot Emphasis C3 RLSL
Sidebend slightly to the LEFT over your THRUST POINT (SB left)
Note:
This SB motion to the left is only meant to tighten the restrictive barrier. It does not reverse the coronal plane

39. Supine-Direct-HVLA Rot Emphasis C3 RLSL
HVLA thrust in rotation
Both hands must rotate!

40. For C2 – C3: Supine – Direct Method – HVLA sidebending emphasis, Kimberly manual, 4421.11A-2, pg 79
Key Points
Contact lower vertebra of the segment
Forward bend
Sidebend over fulcrum
Rotate away
Thrust to opposite orbit

41. Supine-Direct-HVLA The Segment (C3-C4)
C3 RLSL
C3 is the upper vertebra of the segment
C4 is the lower vertebra of the segment

42. Supine-Direct-HVLA C3 RLSL
Support head in LEFT hand

43. Will need to change C3 RLSL
Contact RIGHT articular pillar at inferior border of C3 with thrust contact of RIGHT hand
use lateral margin of index finger
intent is to close facet joint C3 on C4 3 4

44. Supine-Direct-HVLA C3 RLSL
Contact RIGHT articullar pillar of C4 with thrust contact of RIGHT hand
use lateral margin of index finger
intent is to close facet joint C3 on C4

45. Supine-Direct-HVLA C3 RLSL
Forward bend with a tight contact at the RIGHT articular pillar of C3/C4

46. Supine-Direct-HVLA C3 RLSL
Maintain tight contact in FB
Sidebend RIGHT over your thrusting fulcrum at C3/C4

47. Supine-Direct-HVLA C3 RLSL
Rotate to the LEFT to tighten the barrier
Do not lose previous localization!!

48. Supine-Direct-HVLA C3 RLSL
HVLA thrust toward opposite orbit of eye
glide C3 into C4 to close facet
counterforce must be maintained with Right hand

49. C4 – C7 Supine – Direct Method – HVLA, Kimberly manual, 4221
C4 – C7 Supine – Direct Method – HVLA, Kimberly manual, B-1, pg 81
Key Points
Contact upper vertebra of the segment
Forward bend
Sidebend over fulcrum
Rotate away
Thrust to opposite scapula

50. Supine-Direct-HVLA The Segment (C4-C5)
C4 RLSL
C4 is the upper vertebra of the segment
C5 is the lower vertebra of the segment

51. Supine-Direct-HVLA C4 RLSL
Support head in LEFT hand

52. Supine-Direct-HVLA C4 RLSL
Contact RIGHT articular pillar of C4 with thrust contact of RIGHT hand
use lateral margin of index finger or MP joint
intent is to force C4 down onto C5 4 5

53. Supine-Direct-HVLA C4 RLSL
Contact RIGHT articullar pillar of C4 with thrust contact of RIGHT hand
use lateral margin of index finger
intent is to force C4 down onto C5

54. Supine-Direct-HVLA C4 RLSL
Forward bend with a tight contact at the RIGHT articular pillar of C4

55. Supine-Direct-HVLA C4 RLSL
Maintain tight contact in FB
Sidebend RIGHT over your thrusting

56. Supine-Direct-HVLA C4 RLSL
Rotate to the LEFT to tighten the barrier
Do not lose previous localization!!
Final adjustment of flexion/extension in sagittal plane

57. Supine-Direct-HVLA C4 RLSL
HVLA thrust toward opposite inferior angle of the scapula
force C4 down onto C5