Upper Cervical Manipulation

It is recommended that mid-cervical manipulation is learned before this tricky technique.

1. The patient should be supine, with head and neck extending beyond the head of the table, or at the end of the table with a pillow as pictured in the video (either position can work for this technique).
2. The table should be as high as possible to reduce the amount of forward bending the therapist must perform to get into position.
3. It is recommended that these techniques are done with the therapist standing behind the patient's head.
   • Sitting is not recommended. It is very challenging, to achieve the ideal motion and velocity in a seated position.

Passive Motion Assessment

1. It is not possible to use the "piano grip" for stiffness assessment for the upper cervical spine considering the occiput and C1 do not have spinous processes.
2. Motion can be assessed using a unilateral posterior-to-anterior cervical mobilization  or by subjective assessment of "jut" and "nod"

Lockout Position:

Blocking the lower segment for C1/C2 can be performed similarly to the mid-cervical spine:

• Press into the laminar trough and the highest spinous process you can palpate (C2 is the first vertebrae with a spinous process), on the side opposite the closed facet, with the second metacarpophalangeal (MCP) joint (the pad at the base of your index finger). It helps to press into the segment obliquely, in a lateral and vertical direction toward the opposite side ceiling.

Blocking for Occ./C1 requires a different hand position:

• Wrap your hand under the cervical spine, and use the fingertip of the 2nd or 3rd finger to firmly press into the posterior aspect of the transverse process of C1 on the opposite side. Keep in mind, you are trying to block rotation in the same direction as your manipulation. It may also be helpful to attempt simultaneously blocking the spinous process of C2 with the MCP of the same finger/hand. This is tricky and takes practice.

Locking upper segments:

1. Use the other hand to either cup the back of the head firmly with an open hand, or use the head cradle position. The head cradle position is recommended if new to this technique.
2. In the head cradle position the back of the crown of the patient's head is placed in the crease of the elbow, the top of the patient's head is often pressed against the upper chest, and the forearm courses behind or over the back of the ear toward the patient's cheekbone. The hand wraps around the bottom of the jaw. The head should be able to be controlled by the pressure between the chest forearm, and the opposite hand blocking the lower segment. Little if any pressure should be necessary on the chin.
   • Note: Again, this sounds more complicated than it probably is. Once the position is learned, it is fairly easy to replicate.
3. Maintaining pressure with the "blocking hand", gently protract (jut), side-glide away (generally, this takes a slight increase in pressure from the blocking hand as well to not lose lock of the bottom segment)
4. Contralaterally rotate the neck to end-range rotation. Adding a small amount of traction may help.
5. Add a little extension and adjust rotation and lateral flexion until you hit a relatively "solid" end feel. This is the lock position.

High-Velocity Thrust

Important Note: 90% of manipulation technique is set-up. If you have not achieved lock-out in the previous steps, having great "thrust technique" will be rendered useless.

1. The motion is mostly contralateral rotation with a little lateral flexion.
2. You will need to rapidly twist the head and simultaneously increase pressure with the blocking hand to ensure you do not lose the block on the lower segment spinous process.
3. Visualize this small motion (maybe 2 - 3".). You are trying to force "one joint" past its resistance barrier.
4. Ensure the patient is not guarding.
   • Tip: have the patient take a deep breath or wiggle their toes. Your goal is to distract them so that they allow you to passively control their head and neck with as little muscle activity as possible.
5. Quickly, thrust the patient into the new position.
6. Without letting go of the patient's head, gently return the head to neutral position and passively test range of motion.