Physical Therapy for Cervical Spine

Functional Anatomy
⚫ Structures of the cervical region
1. Osseous structures
 Cervicoencephalic or cervicocranial region (C0 – C2): occipital condyles, atlas, and axis.
 Cervicobrachial area: lower cervical spine (C2 – T1).

2. Joints
 Atlanto-occipital joint (C0 – C1)
A. One true convex-on-concave joint in the spine.
B. Two concave superior facets of the atlas articulating with the two convex occipital condyles
of the skull.
→ Superior facets of the atlas 的構造呈現外高內低的狀況.
C. Nodding of the head (15° - 20° flexion-extension) is the primary movement.

 Atlantoaxial joint (C1 – C2)

A. Median atlantoaxial joint (pivot joint) between the dens and the atlas (anterior arch).
B. Two lateral joints (plane joints) between the superior facets of the axis and the inferior facets
of the atlas.
C. Rotation (approximately 50°) is the primary movement.
 Zygapophyseal (apophyseal or facet) joints of the lower cervical region (synovial joints).
 Unocovertebral joint (joints of Luschka): articulations between the uncinate process and adjacent
part of the superior vertebra (C2 or C3 – C7).
 Intervertebral joints: intervertebral disk (except C0-C1 and C1-C2).
3. Ligaments
 Alar ligaments and apical ligament: connect the dens to the occiput (bypasses C1).
A. Alar ligament is a major portion of the stabilization system of the upper cervical spine.
B. Limit contralateral lateral flexion and rotation movement of the occiput on the cervical spine.
  Cruciate (cruciform) ligaments and transverse ligament
A. The principle role of the transverse ligament is to prevent the atlas from translating anteriorly
on the axis during head flexion.
 Tectorial membrane (C2-occiput):
A. Becomes tight with flexion of the head.
B. A prolongation upward of the posterior longitudinal ligament (ends at C2) of the vertebral
column (bypassing the C1).

 Anterior and posterior longitudinal ligaments (ALL and PLL) and ligamentum flavum (C2 – C7).
 Interspinous, supraspinous, and nuchal ligaments.
4. Muscle groups

 Deep anterior neck muscles

 Superficial anterior neck muscles
A. Sternocleidomastoid (SCM)
- Bilateral contraction: neck (lower C spine) flexor and head (upper C spine) extensors.
→ Hold neck and head in the forward-head, chin-out posture in muscle spasm or injured.
- Unilateral contraction: the head and neck are laterally flexed and rotated to the opposite
side.
 B. Scalenus muscles: anterior/medius/posterior
- The scalenes anterior and medius are the anterior and posterior walls of the thoracic
outlet.
- Hypertrophied or in spasm may impinge on the lower roots of the brachial plexus or the
subclavian artery.
Mandibular elevator group (masseter, temporalis, and medial pterygoid muscles) and suprahyoid
and infrahyoid groups
A. The deep craniovervical flexor muscles have segmental attachments and provide dynamic
support to the cervical spine and head.
B. The longus colli is important in the action of axial extension (retraction) and works with the
SCM for cervical flexion.
 Superficial posterior neck muscles: upper trapezius, levator scapulae, splenius capitis & cervicis.
 Deep posterior neck muscles: semispinalis cervicis, multifidus, and rectus capitus posterior major
& minor (belongs to suboccipital muscle groups).

5. Innervations
 Nerve roots (C1 – C8).
A. 臨床上常會根據神經根的損傷位置來推論相關的構造受損
B. 在 C4 與 C5 的頸椎受損時，受到影響的構造分別有 C4 disc, C5 nerve roots.
 Sinuvertebral (recurrent meningeal) nerves: provide sensory and sympathetic nerve supply to
connective tissues associated with the intervertebral discs.
 Brachial plexus:
A. Nerve roots of the C5 – T1 (C5-C6: upper trunk, C7: middle trunk, C8-T1: lower trunk).
B. Erb-Duchenne paralysis (upper nerve roots injured)
- Primarily the muscles of the shoulder region and elbow are affected.
- The muscles of the hand (especially the intrinsic muscles) are not involved.
- Sensation over the radial surfaces of the forearm and the hand and the deltoid area are
affected.
C. Klumpke paralysis (Dejerine-Klumpke palsy) (lower nerve roots injured)
- The obvious changes are in the distal aspects of the upper limb.
- Atrophy and weakness in the muscles of the forearm and hand as well as in the triceps.
- Sensory loss occurs primarily on the ulnar side of the forearm and hand.
 6. Blood supply
 Subclavian arteries: pass between the scalenus anterior and scalenus medius.
 Vertebral artery:
A. Extends from the subclavian artery to the C6 transverse forearm runs to C1.
B. The artery enters the forearm magnum to join the opposite artery to from basilar artery.

C. If the circle of Willis is incomplete or if there is interruption of the blood supply through the
carotid arteries, the vertebral arteries may form a major portion of the blood supply for brain,
particularly the brain stem and cerebellum.
D. The greatest stresses on the vertebral arteries and having the greatest potential problems:
between C1 and C2, and between C1 and the entry of the arteries into the skull.
E. Partial occlusion: extension or full rotation of the cervical spine.
Maximal occlusion: combination of extension and rotation (opposite vertebral artery block).
⚫ Joint Mechanics
Upper cervical spine (AO joint & AA joint)
1. Flexion (nodding the head) / extension.
2. Couple movements: sidebending always accompanies rotation to the opposite side.
 Lower cervical spine

1. In full flexion, the ligaments of the joint capsule are also taut, but the surface of the joint are barely
engaged, making flexion the position of instability.
2. In extension, the articular facets and joint capsules are maximally taut and are in the opposition of
maximal stability of the cervical spine (the closed-packed position).
3. Couple movements: rotation and sidebending in the same direction.
 Inferior glide of the articular facet joint on the side of the spine is rotated or sidebent.
 Superior glide of the articular facet on the side opposite rotation.
4. The intervertebral foramen opening on neck flexion and narrowing on beck extension.
⚫ Stability System of the Cervical Spine
1. Three subsystems of the spinal stability: passive, active, and neutral control (mechanoreceptor in
the locomotor system and neutral control centers).
 Passive stability of the spine comes from the tripod configuration of the two posterior facet joints
and the anterior disk, capsules, passive properties of muscles and spinal ligaments.

 The active subsystem: global and core muscles.

A. The deeper core muscles, which have segmental attachments, provide dynamic support to
individual segments in the spine and help maintain each segment in a stable position.
- Deep cervical extensors (DCE) (e.g., multifidus, semispinalis cervicis, rectus capitus
posterior major and minor) and deep cervical flexors (DCF) (e.g., rectus capitis anterior
and lateralis, longus colli and longus capitis muscles).
- Greater percentages of type I fibers than type II fibers are found in all back.
- Reflective of their postural and stabilization function, emphasis on muscle endurance.
- Only about 10% of maximum contraction is needed to provide stability in usual situation.
 B. The superficial global muscles, being multisegmental, are unable to stabilize individual
spinal segments expect through compressive loading.
C. Both the global and core muscles play critical roles in providing stability to the
multisegmental spine.
D. If an individual segment is unstable, compressive loading from the global muscles may lead
to or perpetuate a painful situation as stress is placed on the inert tissues at the end of the
range of that segment.
 The neutral subsystem coordinates the response of muscles to expected and unexpected forces at
the right time and by the right amount by modulating stiffness and movement to match the various
imposed forces.
 When the cervical spine is positioned in slight lordosis (normal), there is good passive stability
from the facet joints and supporting ligament.
A. Very little muscle contraction is needed to maintain stability in this position.
 When lordosis is lost or the curve is reversed, passive stability is lost, and the core muscles must
go into constant contraction to stabilize the spine.
Common Problems in Cervical Spine
⚫ Postural pain syndrome
1. Pain syndromes related to impaired posture
 Pain results from mechanical stress (a person maintains a faulty posture for prolonged period).
 Pain is usually relieved with activity.

 The faulty posture continues, strength and flexibility imbalance → develop postural dysfunction.
A. The upper crossed syndrome
- Forward (protracted) head, protracted scapulae (round shoulders), and round back
(increased kyphosis), round shoulder, round back.
- A forward head posture
(1) Increased extension of the upper cervical vertebra, and extension of the occiput on
C1 (related to tension-type headache).
(2) Increased flexion of the lower cervical and upper thoracic regions.
(3) Temporomandibular joint dysfunction
- Mobility impairment in the muscles: tightness
(1) Muscles of the suboccipital region (rectus capitis posterior major and minor, obliquus
capitis inferior and superior).
(2) Muscles of the cervical spine and head (upper trapezius, levator scapulae,
sternocleidomastoid, scalene).
 (3) Muscles of the upper extremity originating on the thorax (pectorlais major and minor,
latissimus dorsi).
(4) Intercostalis muscles.
- Impairment muscle performance: weakness
(1) Capital flexors (rectus capitis anterior and lateralis, longus colli, and longus capitis).
(2) Anterior throat muscle (suprahyoid and infrahyoid muscles).
(3) Lower cervical and upper thoracic erector spinae and scapular retractor muscle
(rhomboid, middle & lower trapezius).
2. Treatment
 Awareness and control of spinal posture.
A. Pelvic tilt and control of neutral spine.
B. Axial extension (cervical retraction) to decrease a forward head
posture.
C. Scapular retraction.
 Demonstrate relationship of symptoms with sustained or repetitive postures.
 Stretching for tight muscles and spinal mobilization.
 Exercise for muscle strength and endurance (repetition & holding): core and global muscles.
 Integration of a fitness program, regular exercise and safe body mechanics into daily life.
⚫ Torticollis
Congenital muscular torticollis
1. Seen in infant (presented at birth or developing soon after); involved a lump, or pseudo-tumor over
the unilateral sternocleidomastoid muscle.
2. The resulting deformity: side flexion to the affected side and rotation to the opposite side.
3. Unknown cause but maybe related to abnormal blood supply to the muscle and formed fibrous tissue.

4. Treatments: stretching and overcorrection of the deformity.

 Teach the caregivers how to do stretching and do two to four times a day for at least 1 year.
→ Exercise 1: child undergoing exercise with face looking toward shoulder.
Exercise 2: child undergoing exercise with ear tilting toward shoulder.
Acute or acquired torticollis
1. Usually occurs in people 20 years of age or older.
2. The most common at C2 – C3.
3. That may relate the condition to sleeping in a draft or a similar circumstance and patients commonly
awaken complaining of a crick or pain in the neck (poor neck position for several hours).
4. Postulated causes: a mechanical derangement of the apophyseal joint including trapped or nipped
synovial fringes, capsular tissues, villi or meniscoids.
 5. Unilateral and severe pain at end range on active and passive movement and a decrease in ROM.
6. Spontaneous recovery within 7 days to 2 weeks.
7. Treatment:
 Soft collar for the first few days.
 Soft tissue or/and spinal mobilization / manipulation, muscle energy technique (MET).
⚫ Trauma and Whiplash-associated disorders
1. The Quebec Task Force defined whiplash as an acceleration-deceleration mechanism of energy
transfer to the neck.
2. Injury mechanism: hyperextension-hyperflexion injury of the cervical spine.
 The typical mechanism involves rear-end collision with neck hyperextension (85% of all).
 At movement of impact, the trunk of the body moves rapidly forward, then the moment of inertia
of the head creates a relative backward deceleration of the head and neck.
 Result in bony or soft tissue injuries to the cervical spine and lead to whiplash-associated
disorders (WADs)
A. Injuries seen in hyperextension: disruption of the ALL, disk, articular facet capsule,
muscular strains (SCM, longus colli, scalene), retropharyngeal hematoma, intraesophageal
hemorrhage, and cervical sympathetic chain reaction (Horner’s syndrome).
→ May have difficulty swallowing because of injury to the esophagus and larynx.
B. Injuries seen in hyperflexion: tears of the posterior cervical musculature, sprains of the
ligamentum nuchae and PLL, articular facet joint, posterior intervertebral disk injury with
nerve root hemorrhages.
 3. Common signs:
 Neck pain and headache (usually occurs in the occipital area).
 Anterior neck muscle injury: particularly the SCM and deep anterior neck musculature.
→ The head commonly is held in flexion (with a loss of the lordosis) as a result of muscle spasm,
and ROM is limited, especially side flexion or rotation.
 Referred pain: the interscapular area, the chest, and the shoulders.
4. Treatment:
Acute phase  Soft cervical collar and pain-relieving modalities.
(within 2 – 3 weeks)  Soft tissue mobilization and spinal mobilization (grade I-II).
 Comfortable active ROM exercise as active as possible and should be
rechecked at approximately 1 week intervals.
Subacute phase  Stretch exercise for anterior neck flexor (SCM, hyoid muscle, scalene).
(2 – 10 weeks)  Segmental stabilization exercise.
Chronic phase  Stretch exercise for the posterior nek muscle (suboccipital muscles).
(longer than 6 month) → Chin-in exercise but should be not too long (less than 6 weeks).
 Strengthening exercise are the same as done in subacute phase.

⚫ Neurological problems
Cervical radiculopathy (Compression of nerve roots) (Lateral stenosis)
1. Signs/symptoms: neck pain, shoulder pain, radiating pain in the arm, numbness in the extremity,
muscle weakness, and diminished reflex.
2. Upper nerve roots involved: complain of headaches.
Lower nerve roots involved: complain of neck/shoulder pain.
3. A chronic cervical nerve root condition: often necessary to assess neuromeningeal extensibility
(related to the upper limb neurodynamic test, ULNTs).
4. Causes:
 Degenerative joint disease (DJD)/cervical spondylosis
A. It is a chronic and commonly progressive degeneration of the cervical facet joints and/or the
intervertebral disk (preferentially C5 – C7).
B. The cause is unknown but may be related to spur formation and overuse, genetic, trauma.
C. Spur formation develops along the margins of the disk, the joint of Luschka, and along the
articular facet joints.
- Narrowing of the intervertebral foramina, osteophyte spurring and irregularity.
D. Generally have a forward-head position.
E. Correlation between the degree of radiographic change and the presence or severity of pain
is poor.
 Disc herniation
A. Four types of disc herniation

B. The C5 – C6 and C6 – C7 disc most commonly affected, but less common in the cervical
spine than the lumbar spine.
C. Posterolateral herinations produce the greatest number of clinical signs and symptoms.
→ Due to the strength of posterior longitudinal ligament.
D. Activities may change the symptoms:
- Aggregative pain: cough or sneeze, Valsalva maneuver, or positional foraminal
compression maneuvers (e.g., cervical extension and rotation).
- Relieving pain: cervical distraction.
E. Treatments:
Early phase Postural re-education, soft collar, pain-relieving modalities.
Soft tissue mobilization, spinal mobilization (grade I-II), traction gentle.
ROM exercise (no excessive extension/rotation).
Late phase Spinal mobilization (grade III-V), stretching, strengthening (including
segmental stabilization exercise), nerve mobilization.
Cervical myelopathy (compression of spinal cord) (central stenosis)
1. Sign and symptoms: spastic paraparesis, stiffness and heaviness, weakness, hyperreflexia of knee
and ankle jerks, positive Babinski’s sign or Hoffmann’s sign.
2. Degenerative joint disease (DJD)/cervical spondylosis
 If the spurring continues, it eventually compresses the spinal cord, which is called central stenosis.
 Causes: mainly central posterior herniation, osteophyte, and others (e.g., hypertrophy of the
ligamentum flavum, hypertrophy of the lamina or facet joint).
 An abnormal narrowing of the spinal canal that may occur in any of the regions of the spins.
 A. Ratio of the spinal canal diameter to the vertebral body diameter (Torg ratio = BC/AB) less
than 0.8 → an indication of possible cervical stenosis (normal is 1).
B. A static measurement and may not apply to stenosis that occurs during movement of the
cervical spine.
 Treatments:
A. Mild, nonprogressive causes of cervical myelopathy can be treated similarly to
radioculopathy.
B. Closely neurologic follow-up should assess for deterioration.

Differential diagnosis
⚫ Facet (apophyseal or zygapophyseal) joint syndrome
1. A significant origin for chronic neck pain, particularly in the upper cervical spine.
2. In most cases facet joint syndrome is believed to be the result of a synovial reaction.
 Symptoms: muscle spasm and pain.
 Referred into specific areas depending on the facet joint involved.
3. Treatments:
 Spinal mobilization (grade I-II to involved segments and grade III-V to hypomobile segments
above and below).
 Soft tissue mobilization, active ROM exercise, and segmental stabilization exercise.
⚫ Tension-type headache and cervicogenic headache
1. Musculoskeletal headache may result from tension, cervical spine impairments, or TMJ
dysfunction (a common complaint with impaired posture).
Tension-type headache (TTH)
1. Causes:
  Headaches may follow soft tissue injury or may be caused by a faulty or sustained postures.
 Sustained suboccipital muscles contraction leading to ischemia.
 Greater occipital nerve irritation or impingement (through the neck extensor muscles where they
attach at the base of the skull).

2. History:
 The location of the pain is bilateral in either the head or neck.
 The quality of the pain is steady (pressing or tightening) and nonthrobbing.
 The intensity of the pain is mild to moderate.
 There is no aggravation of the headache by normal physical activity (e.g., walking, stairs…).
Cervicogenic headache
1. It is difficult to define and classify because of its distribution and character of symptoms, which are
similar to those of other forms of headache.
2. Related to upper cervical spine lesion.
3. The most common causes: degenerative joint disease or trauma (e.g., whiplash injury).
4. Symptoms/signs: may mimic those commonly associated with primary headache disorders.
 Unilateral headache without side-shift.
 Pain starting in the neck (e.g., occipital or suboccipital area), spreading to oculo-fronto-temporal
areas; suboccipital or nuchal tenderness.
 Moderate to severe intensity and varying duration or fluatuating continuous pain; usually of a
nonthrobbing pain.
 Pain triggered by neck movement or sustained awkward posture and/or external pressure in the
posterior neck or occipital region.
 Abnormal mobility at C0-C1; reduced ROM.
5. Treatments:
 Pain management: modalities, massage, and muscle-setting exercise.
 Mobility impairments and impaired muscle performance:
A. Increase joint mobility and flexibility: joint mobilization and manipulation, stretching and
soft mobilization (particularly for the upper cervical extensors).
B. Strengthening (e.g., lower trapezius, rhomboids, and serratus anterior muscles) and
segmental stabilization exercise (including retaining cervical joint position sense).
 Stress management: relaxation technique.
⚫ Cervical spine instability
1. More segmental movement may occur owing to disc degeneration, spondylosis ( 椎 弓 斷 裂 ),
spondylolisthesis (椎弓滑脫), spondylitis (脊椎炎), spondylolysis (椎弓發炎), ligamentous laxity.
2. Poor neuromuscular control of the deep segmental stabilizing muscles in maintaining the neutral
zone because of fatigue, altered recruitment pattern, flex inhabitation from pain, or some pathology.
A. Upper cervical instability more frequently occurs in patient with rheumatoid arthritis, post
trauma or congenital problems (Downs’ syndrome) → most cases without neurological signs.

3. If there is an increase in the neutral zone in the cervical spine, the segment may show signs of
instability.
4. Much of the stability in this region is imparted by the dynamic control of the active muscular system.
5. Treatments: spinal mobilization to restore ROM, segmental stabilization exercise.