Cervical osteopathy

The cervical region is a pathway between the head and the thorax consisting of vascular, musculoskeletal, and neural networks; it is one of the most common areas of dysfunction, often resulting in discomfort and impairment. It is imperative that any cervical dysfunction is treated with care. Therefore, understanding diagnostic steps and treatment of the cervical spine are of great importance in osteopathic medicine. Dysfunction may occur in a multitude of anatomical locations: paraspinal musculature, atlanto-occipital (OA) joint, atlanto-axial (AA) joint, or any of the cervical vertebrae (C2–C7). Osteopathic treatment includes various myofascial techniques, muscle energy, facilitated positional release, Still technique, and high-velocity low-amplitude (HVLA).

Cervical Spine

Bones

• See “cervical spine” in the article on the vertebral column.

Osteopathic landmarks of the cervical spine

• Anterior landmarks
  • C2: angle of mandible
  • C3: level of hyoid
  • C4: superior aspect of thyroid cartilage
  • C5: body of thyroid cartilage
  • C6: first cricoid ring
  • C6 (anterior tubercle/transverse process): carotid tubercle
  • T2: suprasternal notch

Motion

• OA joint
  • Primary motion: flexion and extension
  • Secondary motion: side bending
  • Side bending and rotation occur in opposite directions (“opposite always”)
• AA joint
  • Primary motion: rotation
• C2–C7 joints
  • Axes:
    • Rotation: superior-inferior
    • Side bending: anterior-posterior (∼ 45 degrees)
    • Flexion and extension: medial-lateral
  • Side bending and rotation occur to the same side

Spurling maneuver (neck compression test)

• See “Spurling maneuver” in the article on degenerative disk disease.

Wallenberg test

• Function: : assesses vertebral artery insufficiency
• Position: supine
• Procedure
  1. Flex the neck and hold for ten seconds.
  2. Extend the neck and hold for ten seconds.
  3. Rotate the neck to the right and hold for ten seconds.
  4. Rotate the neck to the left and hold for ten seconds.
  5. Rotate the neck to the right in the extended position and hold for ten seconds.
  6. Rotate the neck to the left in the extended position and hold for ten seconds.
• Positive test: lightheadedness, visual disturbance, or ocular nystagmus
  • Indicates vertebral insufficiency

Cervical soft tissue release (passive)

• Position: supine
• Procedure: Apply a slow and gentle force to loosen hypertonic muscles.
  • Apply perpendicular stretch by applying traction to the cervical paraspinal muscles with fingertips.
  • Apply the parallel stretch by holding cervical paraspinal muscles with fingertips.

Cervical soft tissue release (active direct)

• Position: supine
• Procedures
  • Bilateral treatment
    1. Flex the neck and stabilize shoulders by crossing your arms underneath the neck.
    2. Push the shoulders downward and further flex the cervical spine to its barrier.
    3. Ask patient to extend the neck against your equal resistance.
    4. Relax and repeat.
    5. Apply passive stretch.
  • Unilateral treatment
    1. Have patient rotate their head toward the affected side.
    2. Support the head with one arm crossed underneath the neck.
    3. Push the shoulder downward and further flex the neck to its barrier.
    4. Ask patient to extend the neck against your equal resistance.
    5. Relax and repeat.
    6. Apply passive stretch.

Cervical soft tissue release (active indirect)

Uses reciprocal inhibition to relax posterior hypertonic musculature by activating anterior cervical muscles (isokinetic contraction)

• Position: supine
• Procedure
  1. Bring the patient's head gently off the table.
  2. Ask patient to flex the neck against your isokinetic resistance.
  3. Relax and repeat.
  4. Have patient turn their head toward affected side for unilateral treatment.

Suboccipital release

• Position: supine
• Procedure
  1. Place finger pads in suboccipital space.
  2. Hold and allow muscles to relax.
  3. Bring elbows together, lean back, and apply gentle superior traction.
  4. Hold until muscles soften and a release is felt.
  5. Reassess.

Diagnosis

Static examination

• Position: supine
• Procedure
  1. Compare the depth of occipital sulci.
     • Place finger pads between occipital condyles and atlas.
     • Greater depth on one side indicates rotational freedom of motion to that side (e.g., if the occipital sulcus is deeper on the left, the OA is rotated to the left).
     • Side bending component is opposite to the rotational component in all OA diagnoses (e.g., if the OA is rotated to the left, it is side bent to the right).
  2. While monitoring occipital sulci, compare depths while flexing and extending the cervical spine
     • Resolution in flexion or extension indicates freedom of motion in that position (e.g., if the occipital sulci become symmetric in flexion, the OA is flexed).

OA stands for “opposite always” → rotation and side bending occur in opposite directions.

Treatment

Muscle energy

• Position: supine
• Procedure
  1. Engage restrictive barriers.
  2. Have patient rotate or side bend to neutral position against equal resistance for 3–5 seconds.
  3. Relax for 5 seconds.
  4. Re-engage barrier and repeat.
  5. Reassess.

Still technique

• Position: supine
• Procedure
  1. Monitor deep sulcus.
  2. Place OA dysfunction into its freedom of motion.
  3. Add a gentle compressive force until motion is felt at the monitoring finger.
  4. Maintain compression for 3–5 seconds.
  5. While maintaining compression, guide dysfunction into its barriers.
  6. Relax.
  7. Reassess.

Diagnosis

Static examination

• Position: supine
• Procedure
  1. Lock OA and C2–C7 joints
     • Flex patient’s cervical spine (∼ 45 degrees).
  2. Compare range of motion
     • Slowly rotate cervical spine to the right and left side.
     • Greater range of motion to one side indicates a restriction to the opposite side (e.g., if range of motion is greater to the left, the AA is restricted to the right).

The AA joint does not have a side bending component to its diagnosis!

Treatment

Muscle energy

• Position: supine
• Procedure
  1. Flex cervical spine to anatomical barrier (∼45 degrees).
  2. Engage rotational barrier.
  3. Have patient rotate neck toward its freedom of motion against equal resistance for 3–5 seconds.
  4. Relax for 5 seconds.
  5. Re-engage barrier and repeat.
  6. Reassess.

Diagnosis

Static examination

• Position: supine
• Procedure
  1. Translate segment to the right and left side.
     • Greater translation (osteopathy) to one side indicates side bending freedom of motion to the opposite side and rotation freedom to the opposite side (e.g., greater translation of C4 to the left indicates it is side bent right and rotated right).
  2. Translate segment in the flexed and extended position.
     • Greater translation (osteopathy) in flexion or extension indicates freedom of motion in that position (e.g., greater translation of C6 in extension indicates it is extended).

Treatment

Muscle energy

• Position: supine
• Procedure
  1. Isolate cervical segment.
  2. Engage restrictive barriers.
  3. Have patient rotate or side bend neck toward its freedom of motion against equal resistance for 3–5 seconds.
  4. Relax for 5 seconds.
  5. Re-engage barrier and repeat.
  6. Reassess.

High-velocity low-amplitude

• Position: supine
• Procedure
  1. Perform myofascial technique.
  2. Contact posterior articular pillar with MCP joint and allow extension over the monitoring finger.
  3. Gently cup the chin and support the head with the opposite forearm or hand.
  4. Side bend the head over the MCP joint.
  5. Keep the head on the midline.
  6. Rotate the head to its barrier.
     • If this position causes dizziness, lightheadedness, pain or any unusual symptoms, return the cervical spine to its neutral position
  7. Exert a rapid, brief rotary thrust over the MCP joint.
     • Direction of thrust:
       • C2–C3 → opposite cheek
       • C4–C5 → perpendicular to the cervical spine
       • C6–C7 → opposite shoulder

Facilitated positional release (flexion or extension dysfunction)

• Position: supine with head off table
• Procedure
  1. Monitor dysfunction at articular pillar of isolated segment with contralateral hand.
  2. Slightly flex to bring cervical spine to neutral.
  3. Add a compressive force with the ipsilateral hand on the head.
  4. Place into freedoms (flexion or extension, side bending, and rotation toward dysfunction).
  5. Hold for 3–5 seconds.
  6. Relax.
  7. Reassess.

Still technique

• Position: supine
• Procedure
  1. Monitor isolated posterior articular pillar.
  2. Place dysfunction into its freedom of motion.
  3. Add a gentle compressive force until motion is felt at the monitoring finger.
  4. Maintain compression for 3–5 seconds.
  5. While maintaining compression, guide dysfunction into its barriers.
  6. Relax.
  7. Reassess.