Cervical Spine Posterior to Anterior Mobilization

Set-Up

1. The patient should be prone, face-down in a "cut-out" or headrest, with a towel placed under the forehead to reduce the force on sensitive cheekbones.
2. Arms should be in a supported and comfortable position to reduce the amount of muscle activity in scapulothoracic and cervicoscapular muscles.
3. The table should be low enough to allow the practitioner to lean forward slightly to get the chest over the cervical spine, with arms fully extended and thumbs in position over the affected segment.
4. Ideally, the set-up would allow the practitioner to oscillate pressure by gently rocking the torso (not by using grip or triceps strength).
   • Note: It is worth spending some time reviewing the anatomy of the cervical spine and practicing on a plastic model before practicing these techniques on a colleague.

Mobilization of the AO joint (palpation of C1)

1. Standing at the head of the table, palpate the patient/client's mastoid process.
2. Just inferior to the mastoid process, and a little deeper into the soft tissue, you can palpate the transverse processes of C1.
3. Once you find the transverse processes of C1 on both sides, imagine a line between those two points. Place your pinkies on the transverse processes of C1 and lay the rest of your fingertips over that line with your index fingers on either side of the midline.
4. Your 3rd and 4th finger are likely a good approximation of the location of the atlanto-occipital joint. On the side, you wish to treat, replace your 3rd and 4th fingers with your thumbs (thumb over thumb).
5. Your force should be directed in a posterior to anterior direction with a slight tilt in the direction of the patient's eyes.
6. You can move to the side of the table of the affected joint to improve body mechanics.

Mobilization of C2/C3

1. Standing at the head of the table, find the first spinous process inferior to the patient's skull.
2. This is the spinous process of C2; note, C1 does not have a spinous process.
3. Slide your thumbs (thumb over thumb) into the laminar trough (the trough created between the spinous and transverse processes), just lateral and inferior to the C2 spinous process, . You should feel a "bump" when strumming laterally, and that bump should like feel like a column or pillar when strumming vertically. At this level that bump is part of the C2/C3 facet joint.
   • The "bump" in the laminar trough, created by the facet joints of the cervical spine, is often referred to as the "articular pillar". In the cervical spine, the facets stacked on top of one another resemble a column or pillar-like you would see in Roman or Greek architecture.
4. Your force should be directed in a posterior to anterior direction.
5. You can move to the side of the table of the affected joints, to improve body mechanics.

Mobilization of the AA joint (C1/C2)

1. Standing at the head of the table, rotate your patient's head toward the affected side (the side you wish to mobilize) about 30°. Usually, this can be achieved by asking the patient to lay the side of their face on the edge of the face cut-out opposite the affected side.
   • Rotation of the head "takes up the slack" in the atlantoaxial joint to ensure that mobilization is applied at the end range.
2. Follow the directions for finding the C2 spinous process.
3. Slide your thumbs (thumb over thumb) into the laminar trough just lateral to the C2 spinous process, so your pressure is applied through the lateral mass of the vertebrae.
4. Your force should be directed in a posterior to anterior direction.
5. You can move to the side of the table of the affected joint, to improve body mechanics.

Mobilization of C3 - T1

1. Start on the side of the segment you intend to treat.
2. Find the spinous process of the affected segment, or the segment exhibiting stiffness.
3. Slide your thumbs (thumb over thumb) just lateral and inferior to the spinous process (the level between the tips of the spinous process), into the laminar trough and onto the articular pillar.
4. Your force should be directed in a posterior to anterior direction. You may need to adjust your fingers slightly inferior or superior to center your pressure over the facet joint and achieve motion in the affected segment.
5. You can move to the side of the table of the affected joint, to improve body mechanics.

Mobilization:

1. Once you have located the segment you wish to mobilize, place your thumbs over the facet joint on the affected side. (Technically this is referred to as a unilateral posterior to anterior mobilization, or unilateral PA (UPA) for short)
2. When you are satisfied with your test motions, identify the amount of pressure required before you first feel resistance, just before articular motion, and then identify the amount of pressure applied before any additional pressure results in no further articular motion.
   • Note: The end of articular motion is the end of glide, not the end of cervical extension or rotation. Locate the point where the joint will not glide any further, but there is little if any osteokinematic motion.
3. Identify the mid-point between the first resistance barrier and articular end-range; approximately 50% resistance.
   • Grade III - Larger oscillations between the first resistance barrier and approximately 50% resistance. Note, these oscillations are large compared to grade IV oscillations, but are still very small motions.
   • Grade IV - Small oscillations at 50% resistance or more.
4. Oscillate at 1 - 2 pulses per second.
5. Continue oscillating until you feel a change in tissue resistance/joint stiffness.