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Cervical Spine Manipulation
Cervical spine manipulation is a form of manual therapy that is used to treat neck pain, headaches and other conditions caused by muscular tightness and joint dysfunction in the neck area. It involves a skilled clinician applying a gentle and specific thrust to the cervical spine that is aimed at restoring normal range of motion and improving function in the surrounding structures such as the muscles, ligaments, tendons, and fascia. Manipulation of the cervical spine can help to improve posture and reduce muscle tension
Transcript
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This is Brent of the Brookbush Institute, and
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in this video we're going to go over
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manipulations or high-velocity thrust techniques. I assume that if you're
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watching this video you're watching it for educational purposes, and that you
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are a licensed professional with high velocity thrust or manipulation
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techniques in your scope of practice. If you are not sure, check with your state
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board. Most physical therapists, chiropractors and osteopaths you're in
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the clear. I believe that ATC's you can't do manipulations in the United States,
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although other countries again check your scope. Of course massage therapists
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and personal trainers these are generally not within your scope. Of
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course you could continue to watch these videos just for educational purposes,
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learn a little Anatomy, learn a little biomechanics. If you're going to do these
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techniques please make sure that you have a good rationale for putting your
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hands on a patient. This should be based on assessment, and if you're going to
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assess I'm hoping that you'll assess use these interventions and reassess, to
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ensure that you're getting the result that you're looking for and have good
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reason to continue using this technique. In this video we're going to go over
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cervical manipulation, or at least mid to lower cervical manipulation. I'm going to
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have my friend Yvette come out, she's going to help me demonstrate. Now if I'm
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doing a cervical manipulation we do have to keep in mind that I'm basing this on
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more than just subjective complaints of neck pain. We can have neck pain for
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hypermobility of cervical segments, if we're doing manipulations it should be
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for hypomobility, or some sort of restriction. So I'm going to base this on
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some sort of assessment for range of motion, for example we could do our
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visual exam of rotation, lateral-flexion, flexion and extension. I might try to add
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goniometry, keep in mind the only reliable goniometric assessment for the
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cervical spine is actually lateral flexion, and you can look that video
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up. Now you might want to continue with some special tests, if you're going to do
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this, the VBI and ligament tests are often brought up as necessary before
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doing a cervical manipulation, that's probably more dependent on what your
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liability insurance states or what insurance companies you're working with
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state have to be done; and the reason why I say that is
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there is very little evidence to suggest that those tests themselves are
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particularly reliable, or that they would give us any indication of somebody who
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could be hurt by a cervical manipulation. So I think cervical manipulation
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injuries are rare, and that's possibly the most important thing to keep in mind.
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If somebody does look like they need this technique due to a mobility
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restriction you should probably move ahead and do so with care, and obviously
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with practice, and we're going to try to show you some pretty conservative
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techniques here. Now after I've gone through my assessments, whether that's
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subjective, objective and special tests including VBI, or it's subjective and
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objective alone, I'm going to go ahead and have Yvette back off the table here so
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our heads hanging, so that now I have control of her head and cervical spine;
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and the next thing I'm going to do is I'm going to use what's called a piano
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finger grip, I like the Maitland school where I'm going to put my fingertips
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between her spinous process. So you can think of her spinous process are
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lined up this way and I'm trying to put my fingers just in between, and what I'm
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going to try to feel for is, do the spinous process move sequentially, right almost
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like dominoes falling they should go tic tic tic tic tic; rather than what
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you'll feel with somebody who has restriction, is you'll get one that moves
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and then maybe two or three that move together. Or you pulling the
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lateral flexion and it's the same thing, where you get one that moves and then a
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bunch that move together. Well you know those segments that are stuck together
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are potentially something that could be helped by a cervical manipulation. So I
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can do this with Yvette here a little lateral flexion, a little rotation and I
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can do both ways, and I do feel a little restriction over what's probably between
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C3 and C5, so those two segments. Now how am I going to manipulate those
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segments, well this was a little confusing when I first got
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taught it, but I think part of the reason why it was confusing is nobody really
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helped me understand that the most important thing about a cervical
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manipulation is finding the lock out position. Finding that position where you
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have all of the joints locked, so that when you do the actual manipulation
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motion the only thing that can move is the segment you're trying to move and
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that comes down to two big things, well maybe more than two big things, but
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two major things are going to be that you block out the lower segments and that
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you get in locked position with the top segments. So what we're going to do is we're
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going to use our second MCP on the spinous process just below the segment we feel
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restriction. You don't even have to necessarily know which segment that is
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to be quite honest. Some people get very detail-oriented about while I'm
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manipulating C4 on C5, or you could just feel for the stiff segments and go after
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that, your accuracy is probably pretty similar either way. So I'm going to put this
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MCP on the spinous process of the lower segment and press it into the articular
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pillar. So you can see I
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start to take up some tissue slack by pushing my MCP in this direction,
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I'm already stabilizing making sure that those lower segments when I rotate this,
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side-bend or extend, I'm resisting all of those motions at anything lower than
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this MCP. Once I have that stabilized I'm now going to use this hand, and you can
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either use an open hand technique which I'm a little less comfortable with quite
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honestly, or you can do head cradle position. So now I have her head
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cradled in my elbow crease there, most of what she's feeling is like my bicep on
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the top of her head. I can almost control all of it just by doing this. I'm
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literally just cradling her head so she feels nice and comfortable and
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stable, and then we're going to wrap our hand around her chin, but keep in mind
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I'm not like yanking on her face. So I have just got her all wrapped
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up so her heads nice and stable, and then once she's nice and relaxed. Now
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I can move around a little bit, ninety percent of this is set up. So I
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know some of you are waiting for me to do the manipulation, just show me the manipulation,
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we got to get it to crack. That's literally the last 10%, and
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potentially the least important point because if you lock somebody up perfect,
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a lot of times they'll move on you, you'll get a cavitation without even
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having to do a high-velocity thrust. So I'm blocking out those lower segments
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here up this way. I'm then going to rotate away, I'm going to side-bend
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towards me. I'm going to extend and flex and you can see now once
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I rotate, side-bend and extend and flex then I search; and what I'm
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searching for is if I push up here, or push sideways here or rotate sideways
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here, I'm moving her head in this general direction. Get used to that
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general direction, you don't even have to think joint actions. So I know you might
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be like, well you've got a contralaterally rotate and ipsilaterally
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flex and extend. That's all great, but if you just think about this
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general motion, and this general motion here, and get all locked up which I am
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right now. Now all I have to do is a little lateral flexion and rotation and
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I guarantee she's going go. So nice deep breath Yvette,
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and that's it. Sometimes it is a surprise to patients. Not everybody is used to
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getting their cervical spine manipulated and I appreciate that Yvette is
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letting me do this for the first time, because she is not somebody who gets
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cervical manipulations done very often. But
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that wasn't that bad, no pain. You can see I didn't
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move that much, it was more of a startle response than it was any sort of like
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pain response. We're definitely not doing big whips this way, or trying to
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press in really hard, it's just getting that lock and then just a quick
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twist; and I think you have seen chiropractors doing it with the open
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hand technique which looks a little bit more impressive. but they just wrap,
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it's a very quick little technique. So let's try that one more
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time, I'll show you from the other side. I'm going to use this knuckle, I'm
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going to get on the spinous process of the segment just below where I think she's
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stuck. Now I could use an open hand technique, and I'll show you the
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open hand technique this time. So I'm still blocking this way and I'm
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still thinking about pushing up in this direction, because I want to
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oppose the lateral flexion this way and I want to oppose the rotation I'm going
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to do. So I'm trying to keep the spinous process below in position, which
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means I kind of have to push up and in this way towards the articular pillar,
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kind of in the direction of my thumb right now. Now I can use this hand kind
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of wrapped around, you can see like I got my thumb up to her maxilla here and I'm
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just wrapped around her head, and I have some some big hands. So it kind of
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depends on your hand size too where you're going to end up
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as far as your fingertips. So don't look at my hands and be like oh that's
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how it's got to be look, you get your hands where they're comfortable. But
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if I think about the same direction of motion, yes we can think about
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it's the lateral flexion and contralateral rotation and all that
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stuff, or you can think of, you're doing this with her head. You're doing
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this general motion with her head and you can add a little bit of this to get
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locked out. Once I'm locked out I'm here, and
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then she takes a nice deep breath for me and all I'm going to do with my hands is
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this sort of thing, because I'm going to push her into lateral flexion and
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rotation this way, which means I'm going to slide my
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hand this way to get that motion. How you feeling Yvette? Okay good, and that's it.
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Sometimes you get a cavitation, sometimes you don't. Never forget
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cavitation does not mean success. Success is performed better on reassessment, the
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manipulation is the manipulation regardless of whether you got a
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cavitation. It could be that I didn't get her locked up enough on that particular
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try, or it could be that I got it. I would still reassess first before I gave this
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one more try, be careful not trying to get a cavitation too many times because
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you think you failed, because what you will do is you'll start to flare people
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up. We do have to keep in mind that high- velocity also means high-intensity, and
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if we keep doing a high-intensity technique to a tissue over and over
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again that maybe is already a little irritable,
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we could start increasing pain rather than reducing pain. How do you feel Yvette?
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Why don't you sit up and take a minute and we'll go to the close-up recap.
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Alright for a close-up recap I brought out the spine model, I wanted to
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show you some of the stuff we were talking about so you have a little bit
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better visualization. So if this is the back of the cervical spine that you
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would be feeling, the first thing you're going to feel is those spinous process and
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when I talked about that piano grip I was talking about putting my fingertips
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between the spinous process, so I could feel them move sequentially like
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one, two, three, four. They should just each move like little
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dominoes falling, and when two spinous process move together that might be an
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indication that I have a little bit of restriction between those segments, so I
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use that piano grip for that. All right that's what it would look like from
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the other side, and of course then I'm rotating and side-bending. When I talked
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about putting my second MCP against the spinous process, realise
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I'm trying to fit it in this laminar trough, almost trying to put it on these
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articular pillars; and you can see here the articular pillar is called that
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because when all these facets come together they kind of make this like
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pillar shape. But somewhere between the articular pillar and what this would be
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called would be the laminar trough, is kind of where I'm trying to fit my first
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or my second MCP so that I stabilize the lower segments. Now if I have Yvette go
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ahead and come back here, I'll try to demonstrate for you guys one more time
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in a close-up here. So piano grip, what that would look like on her neck is
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I would feel my spinous process, and then I would just slide my fingers over so I
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was on the side of my spinous process, and then I can laterally flex and rotate
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and see if any of those segments seem to want to move together rather than
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sequentially; and then once I find some segments realize that I'm going to then
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try to place my second MCP right up against that spinous process, or the
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spinous process that's lower than the stuck segment. Once I have that set up
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then I'm going to rotate away, laterally flex towards, but we're talking
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about kind of bending her head or bending her neck over that second MCP;
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and then once she's there and I'm nice and locked up, take a deep breath, I can
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give her a quick little rotation and lateral flexion thrust. So this, and if
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she's locked up properly and we hadn't just done a manipulation on the previous
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take of this video which you just saw,
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she probably would have got a cavitation on that one. But keep
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in mind that cavitations don't mean success, changes on reassessment mean
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success. I hope you found this video very helpful. Grab some friends in
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practice, and if you have any questions leave them in the comments box below. A
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couple of points to recap, knowing your anatomy and knowing your biomechanics
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will certainly help you choose the right technique for the right patient. If
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you're unsure whether manipulations are appropriate due to their higher
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intensity, it's okay to do mobilizations. Most research points to manipulations
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being slightly more effective but mobilizations being very effective, and
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of course we have those videos for you if you want to start with those less
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intense techniques. Make sure that if you are doing any technique that is based on
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assessment, and of course that you're reassessing ensuring that the technique
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is effective for the patient that you're working on, and when it comes to all
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manual techniques, manipulations may be more than any other, look for
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opportunities to get live education. Although I know videos are convenient
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and I'm happy to have these up for you to watch, it would be so much more
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helpful to use those videos as a recap of one-on-one attention with somebody
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who's experienced with manipulation techniques. At the very least grab a
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colleague, grab a friend and start practising these before you bring them
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into clinic and start using them on patients and clients. I hope you enjoyed
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this video, if you have any questions please leave them in the comments box
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