1. Tara Jo Manal PT, DPT, OCS, SCS Greg Hicks PT, PhD
Cervical-Throacic Evaluation and Treatment Development of a Clinical Prediction Rule
Tara Jo Manal PT, DPT, OCS, SCS
Greg Hicks PT, PhD

2. Special Tests
Debate in the meaningfulness and usefulness of Vertebral Artery Testing
? Interpretation of a negative test
If positive, further evaluation is indicated

3. Vertebral Artery Test
Combined Movements to stress test the cervical spine
Symptoms:
Dizziness -Tinnitus
Lightheadedness
Nystagmus -Parathesia
Dysarthria - Diplopia
Dysphagia

4. Vertebral Artery Preliminary Test
Patient is sitting. Sustain cervical extension for 10 seconds.
Sustain Rotation (L and R) 10 seconds
IF POSITIVE STOP
If the testing is negative progress to standard position.

5. Vertebral Artery Standard Test
Patient is supine. Sustain cervical extension for 10 seconds.
Sustain Rotation (L and R) for 10 seconds
Combine Extension with Rotation (L and R) for 10 seconds.
Test the patient in the manipulation position
IF POSITIVE STOP, do not manipulate

6. Cervical Distraction Nerve Root Compression
Radicular pain is decreased, test is positive

7. Cervical Compression Test
Pressure downward on head
Test is positive if pain is evoked

8. Spurling A Seated Neck Side bent to the ipisilateral side
7kg of overpressure applied
Presence of pain, parasthesial or numbness

9. Spurling B Seated Extension
Sidebending and Rotation to the ipsilateral side
7kg of axial pressure is applied

10. Sharp –Purser Test Neck in semi flexion Palm of one hand on forehead
Index finger on Spinous process C2
Posterior force through forehead
Posterior slide is + for AA instability

11. Shoulder Abduction Sign
Most common nerve root compression at C5-6
Decrease in symptoms is positive response

12. Median Nerve Testing Shoulder Retraction and Depression
Shoulder Extension
External Rotation
Elbow Extension
Forearm Supination
Wrist/Finger Extension
Cervical SB and Rot Away

13. Upper Limb Tension Testing A
Scapular Depression
Shoulder Abduction
Shoulder ER
Elbow Extension
Forearm Sup
Wrist and Finger Extension

14. Radial Nerve Testing Proximal as for Median Shoulder Internal Rot
Forearm Pronation
Wrist Flexion
Ulnar Deviation
Finger Flexion

15. Upper Limb Tension Testing B
Supine in 30º Abd
Scap Depression
Shoulder IR
Elbow Extension
Wrist and Finger Flexion
Opposite Cervical SB and Rot

16. Ulnar Nerve Testing Shoulder Retraction Shld Ext and ER Elbow Flexion
Forearm Supination
Wrist Extension and Radial Deviation
Finger Extension
Cervical SB and Rot away

17. T1 Nerve Root Stretch Abduct to 90º Flex pronated arms to 90º
Flex elbows and place behind the neck
Pain in scapular area is T1- Pain in Ulnar distribution is Ulnar

18. Thoracic Outlet Roos Test
Standing Abduct arm to 90°
ER shoulder
Open and Close hand for 3 minutes
Positive if unable to maintain position or heaviness/tingling in arm

19. Thoracic Outlet Adson Maneuver Supine Palpate Radial Pulse
Abduct, Extend and ER arm
Take deep breath and rotate toward arm
+ Subclavian if change in radial pulse

20. Thoracic Outlet Halstead Maneuver Palpate radial pulse and distract UE
Patient extends and rotates cervical spine to opposite side
Positive for TOS if absence of pluse

21. Tara Jo Manal PT, DPT, OCS, SCS Greg Hicks PT, PhD
Cervical Evaluation
Tara Jo Manal PT, DPT, OCS, SCS
Greg Hicks PT, PhD

22. Determining Severity Stage 1
Inability to perform basic mechanical functions
Stand for 15 minutes
Sit for 15 minutes
Walk greater than ¼ mile
Cervical Oswestry (NDI) ≥ 30%
Often as high as 50% (less than 2 wks otherwise r/o symptom magnification)
Tx- Pain modulation and movement

23. Stage 1 Treatment Joint Manipulation\Mobilization Traction
Active Spinal Movement
Sleeping Postures
NSAIDS
Physical Agents
Cervical Collar (rest from function only)

24. Determining Severity Stage II Treatment Unable to carry out ADL’s
Vacuum, lift, push, pull
Oswestry (NDI) 20-30%
Treatment
Weakness
Tightness
Posture
Body Mechanics
Active Exercise

25. Determining Severity Stage III Treatment- Return to work/play
Can perform ADL’s and high demand for brief time periods
Cannot return fully to high demand activities
Sports, occupational duties, deconditioned
Cervical Oswestry(NDI) ≤ 20%
Treatment- Return to work/play
Ergonomic Assessment/Modifications
Endurance

26. Assessment of Movement
Cyriax Capsular Pattern
Full flexion, limited extension and symmetrically limited rotation and sidebending
Arthritis, inflammation or DJD of the joints
Flexion is not significantly involved since the neck tolerates flexion well
Restricted flexion
Upper Thoracic and Cervicothoracic junction

27. Range of Motion Flexion Extension Sidebending Rotation
Note quantity
Quality (deviations/location)
Symptom provocation
Active and Passive overpressure
Clear the shoulder (pain free ROM)

28. Non capsular pattern Flexion is limited (non capsular)
Often cervicothoracic or upper thoracic jxn
Opening Restrictions
Closing Restrictions
Combination Restrictions
Significant dysfunction
Located 2 or more areas
Compensations

29. Referred Symptoms Closing Restriction
Extension and Sidebending reproduce sx’s
Limited Cervical Flexion and symptoms
Not typical decreased cervical flexion with symptoms in upper back
Sidebending to opposite side produces distal symptoms

30. Upper Quarter Screen Spurling’s Hoffman’s Reflex (Babinski of UE)
L’hermittes
Reflexes
MMT
Sensory Testing

31. Consider Disc True limitation in cervical flexion
Radiculopathy recreated with motion
Neurological findings
Refer for MRI

32. Cervical Evaluation Passive Range of Motion with endfeel Joint Play
Central PA glides
Prone unilateral PA’s (facet glides)
Supine downglides
Can perform in Neutral, Flexion and Extension

34. Response to Range of Motion
Capsular Pattern (No Radiculopathy)?
Yes
Determine Stage and Treat
Stage I Mobs, Traction, Modalities, NSAIDS, Sleeping Postures
Stage II Active Exercise, Postural Correction, Daily Activities
Stage III Ergonomic Assessment and Modifications

35. Response to ROM No Capsular Pattern Is Flexion Limited? No Yes
Is there an opening Restriction?
Assess and Tx
C-T and T jxn
Yes No
Joint Mobs for opening
Is there a Closing Restriction?
Yes No
Likely a combined lesion
Joint Mobs for closing

36. Limited Forward Flexion
Traction Manip to C-T Junction and Thoracic
Full Passive Flexion
(see next)
Forward Flexion Still Limited
Try Cervical Traction
Improve:
Continue
No Change:
MRI for mechanical block

37. Full Flexion Opening Restriction No Radicular SXs during movement
Opening Manipulation
+TOS signs
-TOS signs
Joint Mobs for opening
Traction Manipulation
+Radicular SXs on Opening
-Radicular SXs on Opening
Opening Manipulation
ICT

38. Upper Thoracic Manipulation
CT junction
Patient sits far back on table
Stabilize shoulders
Use their hands as fulcrum
Distract upwards
Drop down

39. Thoracic Outlet
Clavicle, 1st Rib and Costoclavicular lig, subclavius and ant scalene
Compression of subclavian or axiallary artery, vein, or brachial plexius (C8 and T1)
Costoclavicular syndrome
Loss space between clavicle and 1st rib
Cervical Rib (<1%) syndrome
Cervical rib from C7 or band of fibrous tissue in area

40. Thoracic Outlet Anterior Scalene Syndrome
Compression of neurovascular bundle between anterior and middle scales
Tingling 4th and 5th digit
Ulnar and Median weakness
If vascular hand edema
Testing should recreate symptoms
Vascular change alone is not predictive
Exacerbated by shoulder hypermobility
Dead arm

41. Full Flexion and Closing Restriction
No Radicular Symptoms on closing
Closing Manipulation

42. Full Flexion and Closing Restriction
Radicular symptoms on closing
+ Neuro Signs
- Neuro Signs
Traction Manip
Opening Manip
+ Radicular
with Closing
Radicular
with Closing
+ Radicular
with Closing
- Radicular
with Closing
ICT
Closing Manip
Traction Manip
Closing Manip

43. Early Treatment for Pain
3 Finger Treatments- Painfree ROM
Neck Retraction
Lateral Flexion
Rotation
Decrease flexion (increase fingers) as pain subsides

44. Early Treatment for Pain
Rest
Throughout day, interrupt activity
Supported Sleep
Butterfly pillow (good cervical pillow)
Upright Posture
Avoid hanging head
Collar As Needed

45. Stage II Treatment Improve Range Improve Stability
Joints, muscles, neural tissue
Improve Stability
Strengthen weak muscles
Improved Postural Control
Improve Aerobic Capacity
Activity endurance

46. Self Stretching/Joint Mobs
Use hands to stabilize cervical spine
SNAG’s with towel

48. Indication for Cervical Manipulation
Most successful in presence of a specific restriction (primarily mechanical block)
T Tenderness
A Asymmetry
R Restriction of Movement
T Tension (muscle and soft tissue) Bourdillon 1970

49. Differential Diagnosis
History
Fracture or Instability
Index of Suspicion Intoxication, LOC, High Energy Injuries
x-rays lateral(flex/ext),AP,open mouth,obliques
Osteophytic Encroachment
Whiplash(acceleration injury)

50. Contraindications to Manipulation
Paget’s Disease
Rheumatoid Arthritis
Osetomyelitis
Ankylosing Spondylitis
Malignancy
Cord and Cauda Equina Syndrome
Vertebral Artery Involvement

51. Complications Due to Manipulation
Neurovascular Complications
Author Cases
Sherman, Smialek &Zane
Grant
Patijin
Terrett
Kunnasmaa & Thiel (Rivett, Milburn 1996)

52. Lee et al. Neurology 1995 Survey of 177 Neurologists
Report of neurologic complications following chiropractic manipulation
102 Complications Strokes Myelopathies Radiculopathies

53. Hurtwitz et al. 1996 Spine Complication Rate 5-10 in 5 to 10 million
Less than 120 cases in English
Primarily Vertebrobasilar accident (VBA)
Brain stem or cerebellar infarct
Cord compression, Fracture, Tracheal rupture
Diaphragm paralysis, carotid hematoma or cardiac arrest

54. Injury on 118 Complications
Initial Complaints
37 (31.5%) Neck Pain
10 (8.5%) Neck stiffness
17 (14.5%) Head and neck pain or stiffness
23 (19.5%) Headaches
31 (26%) Other
Torticollis, back pain, head colds

55. Injury in Manipulation
82% were rotational manipulations
66% had signs or symptoms of VBA
After first manipulation
78% had consequences of VB ischemia
20 died
42 had residual symptoms
Risk for Mild complication 1 in 40,000
Risk for Serious complication 1 in 1 million

56. Complications Resulting from Treatments of the C-spine
Treatment Complication
Manipulation VBA, Major Complication or Death
5-10/10,000,000
Cervical Surgery
15.6/1000 Neurological Compromise
6.9/ Death
NSAIDS Serious GI event
3.2/1000 (age 65+) Bleeding, perforation, or other .39/1000 (<65) resulting in hospitalization or death
1/1000 (Ages combined)

57. Examination Perform an Upper Quarter Screen Check dermatomes
Check myotomes
Check reflexes

58. Range of Motion Cervical spine facet motion
Flexion causes facet opening
Extension causes facet closing
Rotation and Lateral Flexion(SB) occur in the same direction
Rotation and Lateral Flexion cause facet opening contralerally and closing ipsilaterally

59. Cervical Facet Opening/Closing
Maximal Left Opening
Forward Flexion
Right Rotation
Right Sidebending
Maximal Left Closing
Extension
Left Rotation
Left Sidebending

60. Treatment/Manipulation
To Open or Close?
Force a stuck drawer close
Open the drawer fully and then attempt to close it

61. Cervical Manipulation Procedure
Position patient comfortably
Palpate the cervical treatment level
Flex or Extend the neck until tension/approximation is noted at the spinal interspace above the desired level
Rotate the head to end range
During patient exhalation - stress end range
Quickly overpress when the patient relaxes
Reassess the patient’s movement and record

62. Manipulation Position for Right Cervical Closing

63. Alternative to Manipulation
Follow the outlined treatment(no overpress)
Oscillate the head at end range
Traction (manual or mechanical)
Soft tissue Treatment
Modalities
Massage
Seek training with skilled manipulator
Refer patient to skilled manipulator

64. Myth of Manipulation Manipulation is not Manipulation is
Dealing with dislocation/subluxation
Correcting a “little bone out of place”
Restoring a “slipped disc”
Manipulation is
Designed to overcome a motion restriction

65. Cervical Radiculopathy

66. Cervical Case

67. Reliability and Accuracy of Clinical Exam for Cervical Radiculopathy
Wainner Spine 2003
82 Patients with suspected Cervical radiculopathy or carpel tunnel
Electrophysiological Testing
Nerve Conduction Study
Needle Electromyography
Clinical Exam
34 items and 2 raters

68. Wainner Spine 2003 Data Collected Visual Analog Scale NDI
History Questions
MMT of Upper Quarter
Reflexes
Pin prick sensation
Cervical ROM
2 warm up- 1 trial with inclinometer

69. Provocative Tests Induce or alleviate mechanical pressure
Enlarge neural foramen
Stretch or slacken neural elements
Increase intrathecal pressure

70. Wainner Spine 2003 Provocative Testing Spurling A Spurling B
Shoulder Abduction Test
Valsalva Maneuver
Neck Distraction
Upper Limb Tension A and B

71. Cervical Radiculopathy
Upper Limb Tension Test A (symptoms recreated, ≥10° elbow ext. difference or wrist flexion, cervical SB’ing increases sx.)
Involved Cervical Rotation less than 60 degrees
Distraction Test (Supine examiner distracts- symptoms reduced)
Spurling A (Sidebend with compression)

72. Cervical Radiculopathy
Upper Limb Tension Test A
Involved Cervical Rotation of less than 60°
Distraction Test (Reduces symptoms)
Spurling A
( if negative best to rule out)
2 Tests = 21% 3 tests= 65%
4 Tests= 90%
Reference Criterion- Electrophysiological Testing

73. Radiculopathy Treatment
Cleland JOSPT 2005
Diagnosis based on Wainner et al.
Case Series of 10 patients
6 month Follow up

74. Subjects 11 of 28 satisfied criteria Age =  51.7 (S.D. 8.2)
Symptom Duration=  18 weeks (8-52)
Treatments =  7.1 (6-10)
9 of 11 had neck & upper extremity pain(82%)

75. Treatment Cervical and Thoracic Mobilizations Deep neck flexor
Supine flattening cervical lordosis with nod
10 second hold/ 10 reps
Scapular exercises
Middle and Lower trap (prone on plinth)
Serratus Wall push ups
Mechanical traction to centralize or reduce sx’s
Intermittent 30:10 for 15 minutes
8.2 kg (18lbs) increased .5-1kg/visit

76. Cervical Lateral Glides

77. Thoracic Manipulations

78. Outcomes Discharge: 8 of 11 (73%) were negative on cluster of tests
2 had positive Spurling’s but improved function
1 had ULTT and Suprling’s
10 Patients (91%) had clinically meaningful reductions in pain and disability
(> 2-7pt change)
Lasted for 6 months-
45 % had 10/10
50% had mild limitations

79. Expand Criteria
If treatment aimed at thoracic helps with radiculopathy- how about neck pain?

80. Subjects Primary Complaint of Mechanical Neck Pain NDI VAS (0-100)
Nonspecific pain in cervicothoracic jxn worsened with neck movements
NDI
VAS (0-100)
36 subjects

81. Randomized Treatment
Thoracic manipulation
Sham Manipulation

82. Immediate Response to Manipulation

83. Clinical Prediction Rule
Which patients with neck pain can benefit from thoracic manipulation, exercise, and patient education?
Cleland et al. Physical Therapy 2007

84. Clinical Prediction Rule for Neck Pain
Age
Neck pain with and without unilateral arm symptoms
NDI > 10%
Exclusions: Red flags, whiplash < 6 weeks, cervical spinal stenosis, CNS problem
2 signs of nerve root myotomes, sensation, reflexes
Numeric Pain Rating
NDI and FABQ
Distal symptom local
Various measurements
Neurological Screen
Postural assessment
Cervical ROM
Joint Mobility
Strength/endurance of muscles
Spurlings, Roos, Distraction, ULTT

86. Intervention
3 Thrust Manipulations
2 reps of each
Seated Distraction

87. Intervention
Supine Upper Thoracic Manip

88. Intervention
Supine Middle Thoracic Manipulation

89. Other Intervention
Cervical ROM

90. Outcomes Greater than +5 point change on global rating of change
If not achieved after treatment 1, repeated on next treatment
No +5 after 2 treatments= Non Responder