Manual fixation versus locking during upper cervical segmental mobilization. Part 2: an in vitro three-dimensional arthrokinematic analysis of manual axial rotation and lateral bending mobilization of the atlanto-axial joint

BackgroundThree-dimensional kinematic aspects of coupled motion during manual cervical mobilization have not previously been studied. Using an in vitro 3D-motion analysis method, the kinematic effects of two different segmental techniques for axial rotation and lateral bending mobilization of the upper cervical spine were investigated as a second part of the study (in part one, kinematic effects of flexion-extension mobilization have been investigated).MethodsAxial rotation and lateral bending mobilization of the atlanto-occipital and atlanto-axial segments were analysed in vitro using an electromagnetic tracking device. Local reference frames were defined based on bony reference points that were registered using a 3D-digitizing stylus.Five embalmed and one fresh specimen were analysed. Segmental motion was registered simultaneously in the atlanto-occipital and the atlanto-axial joints during manual mobilization through the full range of axial rotation and lateral bending mobility. The 3D-kinematic aspects during regional mobilization were compared with those during segmental mobilization with manual fixation and during segmental mobilization using a locking technique.ResultsDuring both segmental axial rotation techniques of the atlanto-axial joint, a significant reduction of the coupled lateral bending and flexion-extension motion was observed. The locking technique also induced an increase in the main axial rotation component. During lateral bending mobilization of the atlanto-axial joint, the manual fixation technique reduced the effect on the coupled flexion-extension component significantly.InterpretationsThese results suggest that for manual segmental axial rotation and lateral bending mobilization of the upper cervical spine segmental manual fixation or locking may be preferred in different situations depending on the desired effects. This study brings additional information to the data provided by part 1 of this study on the 3D-arthrokinematic effects of flexion-extension mobilization.     

颈枕部三维非线性有限元模型的有效性验证

背景：人体组织属性主要表现为非线性,颈枕部的生物力学特点更易受软组织材料属性变化的影响,因此建立非线性有限元模型与人体真实属性更接近. 目的：构建正常成人颈枕部三维非线性有限元模型并验证其有效性. 方法：利用MarConi MX8000多层螺旋CT对健康成人进行颅底-C3段扫描,获取二维图像.直接读入Dicom格式原始图像,图像分割,数据光顺,三维重建后生成颅底-C3节段脊柱三维实体模型;将此模型导入ScanFE模块,进行体网格划分;在ANSYS 10.0软件中直接导入以上三维模型,构建颅底-C3段内韧带单元,模拟韧带力-位移曲线,建立完成颅底-C3段的三维非线性有限元模型.垂直向下方向施加40 N预载荷,1.5 N？m力矩模拟前屈、后伸、侧屈及旋转运动,对比分析实验结果,判断模型应力分布与临床相符度. 结果与结论：构建的三维非线性有限元模型包括663551个单元,178247个节点.施加预载荷及1.5 N？m力矩后,寰枕关节运动范围为前屈13.3°、后伸11.9°、侧屈4.3°、旋转8.7°;寰枢关节运动范围为前屈15.5°、后伸12.6°,侧屈6.4°、旋转30.8°,与尸体标本实验结果相符.从整个模型的纵向应力分布看,在任何相对位置状态下,枢椎齿状突后方的应力均较高,后伸位时应力增高区域加大.上颈椎的应力主要集中于椎管周围,寰椎侧块两端及枢椎横突的应力则较小.对比研究发现,在不同相对工况下前屈、后伸、侧屈、旋转时C2-C3小关节应力均大于钩椎关节,颈枕部三维非线性有限元模型的应力分布特点符合临床实际情况.结果提示应用多层螺旋CT扫描得到的二维图像及simple ware、Ansys10.0软件,建立的颈枕部三维非线性有限元模型符合人体真实的运动规律,可以很好地模拟颈枕部的生物力学特性.     

Effects of Restrained Cervical Mobility on Involuntary Eye Movements

Abstract

The presumed connection between cervicogenic dizziness, cervical evoked involuntary eye movements and intervertebral joint blocks of the high cervical spine serves as a starting point for the manual therapist in treating patients suffering from neck pain, headache and dizziness. Cervical evoked involuntary eye movements are of diagnostic importance and proprioceptive cervical positional nystagmus is seen as pathognomic for high cervical intervertebral joint blocks. In a period of two years, 157 patients with neck pain, headache and dizziness were referred to and examined in our department. Thirty eight patients were diagnosed as having functional vertebrobasilar insufficiency and 17 patients presented with benign paroxysmal positional vertigo. These 55 patients were excluded from the study. The remaining 102 patients were included in the study. Passive functional tests of cervical motion segments OCC-C1, C1 through C4 according to Van der EI and Dvorák and Dvorák and the test for cervical evoked involuntary eye movements according to Oosterveld were carried out on the last group. In 84 of the 102 patients (82%) the passive functional tests of OCC-C1, C1 through C4 were evaluated as positive for one or more cervical motion segments in one rotational direction; in 18 of the 102 patients (18%) as positive in two rotational directions. In 13 of 102 patients (13%) the cervical evoked involuntary eye movements were evaluated as present for proprioceptive cervical positional nystagmus (mean latency: 4 sec.; frequency: decreasing); in 89 patients (90%) as absent. In 12 of the 13 patients (92.3%) intervertebral joint blocks were present at four levels of the high cervical spine OCC-C1, C1 through C4. There was a significant correlation between the number and level of the blocked cervical motion segments and the presence of the proprioceptive cervical positional nystagmus (Kendall's tau-b = 0.59; p < 0.05). The results of this study are not comparable with those reported in other studies because of differences in the methods and judgement of the cervical evoked involuntary eye movements (ENG versus visual observation using Frenzel's spectacles) and the function of the high cervical spine (no specific information versus manual diagnostic information per cervical motion segment). The findings suggest the need for further research.     

颈椎后前向松动产生的椎间运动和生物力学分析

目的:通过影像学研究颈椎后前向松动产生的椎间运动,分析其生物力学作用。方法:选取正常受试者12例,均采用多功能颈椎康复治疗仪给予后前向颈椎关节松动,力量为10～30N;松动前后,采用静态颈椎侧位片,比较运动节段矢状面的角度旋转及前后椎间隙变化。结果:松动后,C3～C6节段矢状面旋转角度均大于松动前(P<0.05);C3、C5节段前椎间隙均显著大于松动前(P<0.05),C5节段后椎间隙显著小于松动前(P<0.05)。结论:后前向松动明显增加C3～C7脊柱的前凸,在伸展同时椎体产生旋转,前椎间隙增宽,后椎间隙减小。     

The Immediate Effects of Upper Thoracic Translatoric Spinal Manipulation on Cervical Pain and Range of Motion: A Randomized Clinical Trial

This study examined the effect of translatoric spinal manipulation (TSM) on cervical pain and cervical active motion restriction when applied to upper thoracic (T1-T4) segments. Active cervical rotation range of motion was measured re- and post-intervention with a cervical inclinometer (CROM), and cervical pain status was monitored before and after manipulation with a Faces Pain Scale. Study participants included a sample of convenience that included 32 patients referred to physical therapy with complaints of pain in the mid-cervical region and restricted active cervical rotation. Twenty-two patients were randomly assigned to the experimental group and ten were assigned to the control group. Pre- and post-intervention cervical range of motion and pain scale measurements were taken by a physical therapist assistant who was blinded to group assignment. The experimental group received TSM to hypomobile upper thoracic segments. The control group received no intervention. Paired t-tests were used to analyze within-group changes in cervical rotation and pain, and a 2-way repeated-measure ANOVA was used to analyze between-group differences in cervical rotation and pain. Significance was accepted at p = 0.05. Significant changes that exceeded the MDC₉₅ were detected for cervical rotation both within group and between groups with the TSM group demonstrating increased mean (SD) in right rotation of 8.23° (7.41°) and left rotation of 7.09° (5.83°). Pain levels perceived during post-intervention cervical rotation showed significant improvement during right rotation for patients experiencing pain during bilateral rotation only (p=.05). This study supports the hypothesis that spinal manipulation applied to the upper thoracic spine (T1-T4 motion segments) significantly increases cervical rotation ROM and may reduce cervical pain at end range rotation for patients experiencing pain during bilateral cervical rotation.     

Doppler studies evaluating the effect of a physical therapy screening protocol on vertebral artery blood flow

General and isolated cervical positional tests are used to screen for potential vertebro-basilar insufficiency (VBI). There is limited research evaluating vertebral artery blood flow in these positions to justify the rationale of progressive mechanical stress occurring to the arteries. The purpose of the study was to determine vertebral artery blood flow in six cervical positions used in clinical practice. A comprehensive cervical assessment was conducted on 22 men and women (mean age 35) with no known vascular pathology. Vertebral artery peak systolic (PS), end diastolic (ED) flow rates and resistive index (RI) were measured using duplex colour Doppler sonography (sampling at C3-C5) in neutral, rotation, extension, combined rotation-extension, combined rotation-extension-traction, deKelyn's position and a C1-C2 pre-manipulative hold. Results showed there was a significant decrease in PS and ED in the contra-lateral artery during the pre-manipulative hold, and a decrease in ED in the contra-lateral artery during rotation. There was no effect of age, gender or mobility restriction on these blood flow changes. The pre-manipulative hold had the greatest response with 34% of the arteries demonstrating a complete cessation of ED flow. In conclusion the pre-manipulative hold and rotation created the greatest mechanical stress to the contra-lateral vertebral artery. These two positions may be useful screening positions to identify individuals at risk for VBI due to inadequate collateral blood flow.     

Preliminary Report: Biomechanics of Vertebral Artery Segments C1-C6 During Cervical Spinal Manipulation

ObjectiveThe purpose of this study was to measure strains in the human vertebral artery (VA) within the cervical transverse foramina and report the first results on the mechanical loading of segments of the VA during spinal manipulation of the cervical spine.MethodsEight piezoelectric ultrasound crystals of 0.5-mm diameter were sutured into the lumen of the left and right VA of one cadaver. Four hundred–nanosecond ultrasound pulses were sent between the crystals to measure the instantaneous lengths of the VA segments (total segments n = 14) at a frequency of 200 Hz. Vertebral artery engineering strains were then calculated from the instantaneous lengths during cervical spinal range of motion testing, chiropractic cervical spinal manipulation adjustments, and vertebrobasilar insufficiency testing.ResultsThe results of this study suggest complex and nonintuitive strain patterns of the VA within the cervical transverse foramina. Consistent (for 2 chiropractors) and repeatable (for 3 repeat measurements for each chiropractor) elongation and shortening of adjacent VA segments were observed simultaneously and could not be explained with a simple model of neck movement. We hypothesized that they were caused by variations in the location and stiffness of the VA fascial attachments to the vertebral foramina and by coupled movements of the cervical vertebrae. However, in agreement with previous work on VA strains proximal and distal to the cervical transverse foramina, strains for cervical spinal manipulations were consistently lower than those obtained for cervical rotation.ConclusionsAlthough general conclusions should not be drawn from these preliminary results, the findings of this study suggest that textbook mechanics of the VA may not hold, that VA strains may not be predictable from neck movements alone, and that fascial connections within the transverse foramina and coupled vertebra movements may play a crucial role in VA mechanics during neck manipulation. Furthermore, the engineering strains during cervical spinal manipulations were lower than those obtained during range of motion testing, suggesting that neck manipulations impart stretches on the VA that are well within the normal physiologic range of neck motion.     

A comparison of two non-thrust mobilization techniques applied to the C7 segment in patients with restricted and painful cervical rotation

Objectives:

Cervical mobilization and manipulation have been shown to improve cervical range of motion and pain. Rotatory thrust manipulation applied to the lower cervical segments is associated with controversy and the potential for eliciting adverse reactions (AR). The purpose of this clinical trial was to describe two translatory non-thrust mobilization techniques and evaluate their effect on cervical pain, motion restriction, and whether any adverse effects were reported when applied to the C7 segment.

Methods:

This trial included 30 participants with painful and restricted cervical rotation. Participants were randomly assigned to receive one of the two mobilization techniques. Active cervical rotation and pain intensity measurements were recorded pre- and post-intervention. Within group comparisons were determined using the Wilcoxon signed-rank test and between group comparisons were analyzed using the Mann–Whitney U test. Significance was set at P = 0.05.

Results:

Thirty participants were evaluated immediately after one of the two mobilization techniques was applied. There was a statistically significant difference (improvement) for active cervical rotation after application of the C7 facet distraction technique for both right (P = 0.022) and left (P = 0.022) rotation. Statistically significant improvement was also found for the C7 facet gliding technique for both right (P = 0.022) and left rotation (P = 0.020). Pain reduction was statistically significant for both right and left rotation after application of both techniques. Both mobilization techniques produced similar positive effects and one was not statistically superior to the other.

Discussion:

A single application of both C7 mobilization techniques improved active cervical rotation, reduced perceived pain, and did not produce any AR in 30 patients with neck pain and movement limitation. These two non-thrust techniques may offer clinicians an additional safe and effective manual intervention for patients with limited and painful cervical rotation. A more robust experimental design is recommended to further examine these and similar cervical translatory mobilization techniques.     

X-ray image segmentation for vertebral mobility analysis

Objective The goal of this work is to extract the parameters determining vertebral motion and its variation during flexion–extension movements using a computer vision tool for estimating and analyzing vertebral mobility. Materials and Methods To compute vertebral body motion parameters we propose a comparative study between two segmentation methods proposed and applied to lateral X-ray images of the cervical spine. The two vertebra contour detection methods include (1) a discrete dynamic contour model (DDCM) and (2) a template matching process associated with a polar signature system. These two methods not only enable vertebra segmentation but also extract parameters that can be used to evaluate vertebral mobility. Lateral cervical spine views including 100 views in flexion, extension and neutral orientations were available for evaluation. Vertebral body motion was evaluated by human observers and using automatic methods. Results The results provided by the automated approaches were consistent with manual measures obtained by 15 human observers. Conclusion The automated techniques provide acceptable results for the assessment of vertebral body mobility in flexion and extension on lateral views of the cervical spine. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Functional radiographic examination of the cervical spine in patients with post-traumatic headache

The segmental extension-flexion motion of the cervical spine and the overall C1-C7 motion were measured on functional X-rays in 19 patients with post-traumatic headache and 19 age- and sex-matched controls. The extension-flexion C1-C7 motion was reduced in patients with post-traumatic headache due to reduced motion in three segments: C2-C3, C5-C6 (p less than 0.05), and C6-C7 (p less than 0.01). In both groups a negative correlation between the C1-C7 motion and age was found, but the regression coefficients were different. Only in the control group could a negative correlation between segmental motion and age be demonstrated. In the patients with post-traumatic headache a statistically significant negative correlation between the log (pain index) and the age-corrected C1-C7 motion was found (p less than 0.04). On the segmental level a negative correlation between the log (pain index) and the age-corrected C1-C2 and C5-C6 motion could be demonstrated (p less than 0.05). Regarding C6-C7 there was a tendency to negative correlation. Furthermore, a negative correlation between the frequency of associated symptoms (dizziness, visual disturbances and ear symptoms) and the age-corrected C5-C6 motion was found. Consequently the decrement of motion primarily affected C2-C3, C5-C6, and C6-C7, whereas the analysis of correlation with pain index indicated C1-C2 and C5-C6 (C6-C7) as the most important segments involved.     

Normal kinematics of the upper cervical spine during the Flexion-Rotation Test - In vivo measurements using magnetic resonance imaging

The Flexion-Rotation Test (FRT) is proposed to assess mobility primarily at C1-C2. However, there is no in vivo measurement investigating the validity of the FRT. The purpose of this study was 1) to examine measurement reliability of segmental upper cervical movements using magnetic resonance imaging and 2) to investigate the content validity of the FRT. Nineteen asymptomatic female subjects (mean age: 22.2 years) were evaluated with a 0.2-T horizontally open MRI unit. The segmental rotation angles from Occiput-C1 to C3-C4 and the C4 vertebra were assessed with the head maximally rotated to both the right and the left in two conditions - neck in neutral and in flexion. Good reliability of the method of measurement was suggested by error considerations. A repeated measure ANOVA revealed an interaction between the two different neck starting positions and segment levels (P < 0.0001). Post-hoc analysis revealed that there were significant reductions in the flexed position (P < 0.0001) except for at Occiput-C1. While there was only a 16.3% reduction in rotation range at C1-C2, the reduction was 68.1% at C2-C3, 61.4% at C3-C4, and 76.9% at segments below C4, respectively, supporting the content validity of the FRT as a clinical measure of atlanto-axial mobility.     

How does a novel knitted titanium nucleus prosthesis change the kinematics of a cervical spine segment? A biomechanical cadaveric study

BackgroundTotal disc replacement is a possible treatment alternative for patients with degenerative disc disease, especially in the cervical spine. The aim is to restore the physiological flexibility and biomechanical behavior. A new approach based on these requirements is the novel nucleus prosthesis made of knitted titanium wires.MethodsThe biomechanical functionalities of eight human cervical (C4-C7) spine segments were investigated. The range of motion was quantified using an ultra-sound based motion analysis system. Moreover, X-rays in full flexion and extension of the segment were taken to define the center of rotation before and after implantation of the nucleus prosthesis as well as during and after complex cyclic loading.FindingsThe mean range of motion of the index segment (C5/6) in flexion/extension showed a significant reduction of range of motion from 9.7° (SD 4.33) to 6.0° (SD 3.97) after implantation (P = 0.037). Lateral bending and axial rotation were not significantly reduced after implanting and during cyclic loading in our testing. During cyclic loading the mean range of motion for flexion/extension increased to 7.2° (SD 3.67). The center of rotation remained physiological in the ap-plane and moved cranially in the cc-plane (−27% to −5% in cc height) during the testing.InterpretationThe biomechanical behavior of the nucleus implant might lower the risk for adjacent joint disorders and restore native function of the index segment. Further in vivo research is needed for other factors, like long-term effects and patient's satisfaction.     

Morphology and kinematics of the atlanto-axial joints and their interaction during manual cervical rotation mobilization

Background data

At present little data are available on the relationship between spinal anatomy and kinematics. No studies have verified the relationship between atlanto-axial kinematics during manual mobilization and the spatial features of the atlanto-axial ligaments and the lateral joints.

Materials and methods

Twenty un-embalmed cervical spine specimens (9 male and 11 female; 80 ± 11 years) were studied. Atlanto-axial kinematics were registered during manual axial rotation mobilization using an ultrasound-based motion tracking system. Anatomical landmarks were digitized and spatial features of the lateral atlanto-axial joint surfaces and alar ligaments were extracted. The relationship between the anatomical features and the spinal kinematics was analyzed using statistical regression analysis.

Results

Only the range of motion of the coupled flexion–extension motion component, the ratio and the time shift between main axial rotation and coupled lateral bending motion components could be predicted for about 52%, 49% and 73%, respectively, by a selected set of anatomical features.

Conclusion

Supposed relationships between anatomical features and joint kinematics are only partially confirmed. The results indicate that the kinematics of the atlanto-axial joint during manual regional axial mobilization are not completely predetermined by the specimens’ specific anatomy.     

Cervical coupling during lateral head translations creates an S-configuration

OBJECTIVE: To determine cervical coupling during the posture of lateral head translation relative to a fixed thoracic cage. DESIGN: Digitized measurements from anteroposterior cervical radiographs of 20 volunteers were obtained in neutral, left, and right lateral translation posture of the head compared to a fixed thorax. BACKGROUND DATA: Clinically, lateral translation of the head is a common posture. Ranges of motion and spinal coupling have not been reported for this movement. METHODS: Vertebral body corners, mid-lateral articular pillars and the superior spinous-lamina junction of C3-T4 were digitized on 60 radiographs. Using the orthogonal axis of positive x-direction to the left, vertical as positive y and anterior as positive z, digitized points were used to measure projected segmental z-axis rotation, y-axis rotation, and segmental lateral translations of each vertebra. RESULTS: Subjects translated their heads laterally a mean of 51 mm. The major coupled motion was lateral bending (z-axis rotation), which changed direction at the C4-C5 disc space creating an S-shape. Upper cervical (C3-C4) lateral bending was contralateral to the main motion of head translation direction. Lower cervical and upper thoracic lateral bending were ipsilateral. Other segmental motions averaged less than 1 mm and 1 degrees. CONCLUSIONS: Lateral head translations (x-axis) compared to a fixed thoracic cage can be large with a mean of 51 mm to one side. The major spinal coupling was lateral bending which changed direction at C4-C5 resulting in an S-configuration. This might have application in side impacts. All other segmental movements were small, less than 1 mm and 1 degrees. RELEVANCE: The clinically common posture of lateral head translation results in an S-shaped cervical spine and may occur in side impact trauma. This posture has not been studied for cervical coupling patterns or range of motion (ROM).     

Mobility of the cervical spine after anterior interbody fusion for spondylotic myelopathy—a radiographic study

To study the influence of anterior body fusion on the adjacent vertebral discs, the radiographs of 101 patients with cervical spondylotic myelopathy (CSM) were analysed, and cervical mobility and intersegmental mobility were determined. Single level fusions were carried out in 29 patients, double level fusions in 45 patients and triple level fusions in 27 patients. Cervical mobility after surgery was inversely proportional to the number of fused discs. Angles were reduced by fusion in proportion to the number of fused discs. The compensatory increase in motion at the disc adjacent to the fusion was slight, and the number of fused discs had little influence on the compensatory increase in motion. Regarding cervical motion, extension and flexion were limited to the same extent in single level fusions, flexion was more limited in double level fusions and limitation of extension was much larger in triple level fusions.Seven patients underwent a second operation after a double level fusion, and one patient underwent a second operation after a single level fusion. In all five patients whose radiographs before the second operation were available, flexion was adequately limited, but extension was not limited at all. These results suggest that the failure to limit extension is responsible for the recurrence of CSM.     

Acute neck pain: cervical spine range of motion and position sense prior to and after joint mobilization

Despite the relatively high prevalence of cervical spine pain, the efficacy of treatment procedures is limited. In the current study, range of motion and proprioception was assessed prior to and after specific cervical spine mobilisation techniques. A 44-year-old male office worker presented with a history of cervical pain of 1 day duration. He had woken with pain, stiffness and a loss of range of motion. Examination findings indicated pain to be at C5–6 on the left side. Measurement of maximal three-dimensional cervical motion was undertaken using a Zebris system. A position matching task tested the individual's ability to actively reposition their head and neck. The treatment undertaken involved grade III down-slope mobilisations on the left side at C5–6 and C6–7 in supine lying. This technique was then progressed by placing the subject in an upright sitting position, and sustained natural apophyseal glides were performed at C6.Immediately following the treatment, the patient reported a considerable decrease in pain, less difficulty in movement and reduced stiffness. Motion analyses showed the most marked percentage improvements in range of motion after treatment were in flexion (55%), extension (35%), left rotation (56%), and left lateral flexion (22%). Ipsilateral lateral flexion with axial rotation was also notably improved following treatment. No change in proprioceptive ability was found following the treatment. The findings showed that the application of standardised specific mobilisation techniques led to substantial improvements in the range of motion and the restitution of normal coupled motion.     

Effect of adding stretching to standardized procedures on cervical range of motion,pain, and disability in patients with non-specific mechanical neck pain: A randomized clinical trial

Objectiveto investigate the benefit of adding stretching exercises to cervical joint mobilization and active rotation exercises for patients with non-specific mechanical neck pain.MethodsThirty-eight subjects with non-specific mechanical neck pain were randomly assigned to a standard procedure group (passive cervical mobilization and active cervical rotation range of motion exercise) or a combined procedure (passive cervical mobilization, active cervical rotation range of motion exercises, and stretching procedures). Mixed factorial analysis of variance was used to compare changes between groups over time in active cervical range of motion, Numeric Pain Rating Scale, Neck Disability Index, Global Rating of Change, and Pressure Pain Threshold.ResultsThere was a significant change in mean active range of motion in all directions, Pressure Pain Threshold, perceived pain, disability levels, and global rating of change over time (p < 0.001). There was a significant group by time interaction in mean active range of motion during extension (p = 0.01), right rotation (p = 0.004), right and left lateral flexion (p = 0.05, and p = 0.02 respectively). However, there was no significant group by time interaction in mean active range of motion during flexion, left rotation, pain intensity (p = 0.09), right and left pressure pain threshold (p = 0.30, 0.47, respectively), and disability (p = 0.07).ConclusionsBoth study groups improved significantly in all subjective and objective outcome measures. However, data from this study suggest that adding stretching to the standard procedures may be more effective than the standard procedure alone at improving cervical extension, right rotation, and lateral flexion active range of motion, but not pain and disability.     

Differential diagnosis and treatment in a patient with posterior upper thoracic pain

BACKGROUND AND PURPOSE: Determining the source of a patient's pain in the upper thoracic region can be difficult. Costovertebral (CV) and costotransverse (CT) joint hypomobility and active trigger points (TrPs) are possible sources of upper thoracic pain. This case report describes the clinical decision-making process for a patient with posterior upper thoracic pain. CASE DESCRIPTION: The patient had a 4-month history of pain; limited cervical, trunk, and shoulder active range of motion; limited and painful mobility of the right CV/CT joints of ribs 3 through 6; and periscapular TrPs. Interventions included CV/CT joint mobilizations, TrP release, and flexibility and postural exercises. OUTCOMES: The patient reported intermittent mild discomfort after 7 physical therapy sessions. Examination findings were normal, and he was able to resume all preinjury activities. DISCUSSION: This case suggests that CV/CT mobilizations and active TrP release may have been beneficial in reducing pain and restoring function in this patient.     

Experimental cervical interspinous ligament pain altered cervical joint motion during dynamic extension movement

BackgroundAlthough the cervical interspinous ligament is a potential source of neck pain, the effects on cervical joint motion and pressure pain sensitivity has never been investigated. The understanding of the relationship will broaden our understanding of cervical biomechanics and improve diagnosis and treatment of neck pain.MethodsFluoroscopy videos of cervical flexion and extension movements and pressure pain thresholds over bilateral C2/C3 and C5/C6 facet joints were collected in fifteen healthy subjects before and after injections of hypertonic and isotonic saline in C4/C5 ISL. The videos were divided into 10 even epochs and the motion of individual joints during each epoch was extracted. Joint motion parameters including anti-directional motion, pro-directional motion, total joint motion and joint motion variability were extracted across epochs. Joint motion parameters and PPTs were compared before and after injection of hypertonic and isotonic saline separately.FindingsCompared with baselines: hypertonic saline injection 1) decreased anti-directional motion and joint motion variability at C4/C5 (P < 0.05) and increased at C2/C3 (P < 0.05) during extension; 2) increased total joint motion of C0/C1 during first half range (P < 0.05) and decreased during second half range of extension, and total joint motion of C2/C3 increased during second half range of extension (P < 0.05) and; 3) increased pressure pain thresholds over left C2/C3 facet joint (P < 0.01).InterpretationThe cervical interspinous ligament pain redistributed anti-directional motion between C4/C5 and C2/C3 during dynamic extension and decreased pressure pain sensitivity over the left C2/C3 facet joint.