Escolar Documentos
Profissional Documentos
Cultura Documentos
THORACIC SPINE
MECHANICAL
DIGNOSIS &
THERPY
VOLUME ONE
ROBIN MCKENZIE
CNZM, OBE, FCSP (HON), FNZSP (HON), DIP MDT, DIP MT
STEPHEN My
MA, MCSP, DIP MDT, MSc
THE CERVlCAL & THORACIC SPINE
MECHANICAL DIAGNOSIS & THERAPY
BY ROBIN McKENZIE AND STEPHEN MAY
This book is essential reading for any health profesional involved in the management of
patients with cervical or thoracic pain. Describd within are the mechanical measures
required for the diagnois and trtment of the common prblems. The precis identification
and management of subgroups in the spctrum of mechamcal cerical and thoracic disorers
has been sid to be a priority if we are to improve our methods of management of back and
neck problems. This latest book in the sres by McKenzie and May provides a system to
identif subgoups and consequently provide btter strategic solutions.
Robin McKenzie first published his landmark text outlining cenain principles and concepts
for the diagnosis and management of lumbar spine problems in 1981. Another volume
addressing the cervical and thoracic spine w published in 1990. His first publications
always stressed the importance of patient self-management and the relevance of this issue
h been belatedly recognisd by others. Since thes publicatiOns considerable evidence h
demonstrated the imprtance and relevance of thos principles and concepts i t moem
management of musuloskeletal problems.
This edition explains the centralistion and prpheralistion phenomena; the u of exer
to induce changes in pain loation and intensity; the means of detecting the most effective
dirction in which to apply theraputiC exercis; diff erentiation between the pain of
displacement. pain of contracture and pain arising from normal tissue; how to diff erentiate
the pain of nerve root adherence from entrapment and siatica.
This second edition of T Cerical 1 Thoracic Spine: Mechanical Diagosis 1 Therapy
parallels the changes in the updated Lumbar Spine text. It h been thoroughly revisd and
COnsiderably expnded and explor in depth the literature relating to mechanicl syndrmes
and neck and trunk pain In general. There are deSCriptiOns of the management of the three
mechanical syndromes -derangement. dysfunction. and postural syndrome - as applied to
neck. thoracic and headache problems. There is in-depth consideration of the literature
relating to a number of issues. such as the epidemiolog of neck pain. headaches. srious
spinal pathology and whiplash. Opertional defnitions. desriptiOns and numerous tables
provide clinical sigs and symptoms to recognise or suspect mechanical syndromes or
other diagnoss.
Robin McKenzie and Stephen May have produced another evidence-basd and clinically
relevant text for the new century. augmenting the other volumes available that relate to the
lumbar spine and e>1remily problems. It provides a review of relevant general topics as well
as the detail of how to evaluate and prescribe apprpriate specific exercises and manual
techniques. The system desribed in this bok achieves a new benchmark for the non
surgical management of mechamcal cerical and thoracic disrders.
The Cervical & Thoracic Spine
Mechanical Diagnosis & Therapy
Volume One
Robin McKenzie
CNZM, OBE, FCSP (Hon), FNZSP (Ion), Oil' MDT, Oil' MT
Stephen May
MA, MCSp Oil' MDT, M c
Spinal Publications ew Zealand Ltd
Raumati Beach, New Zealand
The Cervical & Thoracic Spine: Mechanical DiagnosIs & Therapy
Firt Edition frst published in 1990 by Spinal Publications New Zealand ltd
Second Edition frst published in April 2006
Reprinted February 2007, March 2008 by
Spinal Publications New Zealand Ltd
PO Box 2026, Raumati Beach, New Zealand
Email: en
q
uiries@spinalpublications.co.nz
Robin McKenzie 2006
All rights reserved. No pan of this publication may be reproduced by
any means, stored in a retrieval system or transmitted in any rorm or by
any means electronic, mechanical, including photocopying, recording or
otherwise, without the prior written permission of the COp)Tight holder.
ISBN 10 0-9583647-7-X
ISBN 13 978-0-9583647-7-5
Design by Next Communications
Edited by Autumnwood Editing and Jan McKenzie
Photography by John Cheese
Illustrations by Paul Pugh
Typeset and printed by Astra Plint
Dedication
To my patients who, from 1953 to 2003, taught
me all I know
i
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l
Foreword
The lumbar spine has two cousins: the cervical spine , which is the
poor cousin, and the thoracic spine, which is the even poorer cousin.
They are poor because they have so little science. Whereas the lumbar
spine has been extensively studied, and some might venture that it i s
even reasonably well underst ood, this i s not the case for the cervical
and thoracic spine s.
Some things are known about the cervical spine. We know its structure;
we know how it works; we have some idea about how it can be
inj ured. We have some understanding of the origins and causes of
neck pain.
The same cannot be sai d about the thoracic spine. We have little
inSight int o how the thoracic spine works. We have essentially no
knowledge of the common causes of thoracic spinal pain. Various
conj ectures have been brought t o bear, but none i s accompanied by
scientifc data.
With respect t o treatment, we have enough studie s t o show that, for
acute neck pain, most interventi ons do not work. Keeping the neck
active is the only intervention that has been shown to be effective. For
chronic neck pain we have little data. For thoracic spinal pain, either
acute or chronic, the literature is devoid of any scientifc data.
It is into thi s environment that Robin McKenzie sends the second
edition of his text. In thi s editi on he reiterates his clinical prot ocol ,
but set s it in the context of what el se is known about cervical and
thoracic spinal pain.
The text provides a thorough and fairly comprehensive review of the
background literature. Readers are appri sed of what i s known about
the epidemi ol ogy and risk factors for neck pain and the little that is
known about thoracic spinal pain. Particularly valuable for physical
therapi st s are suitable acc ounts of the seri ous causes of cervical and
thoracic spinal pain and an account of vertebral artery di sorders and
their recognition.
These accounts reflect what i s available i n the literature. Contributi ons
t o that literature have focussed on what might be construed as the easy
aspects of spine pain: counting its prevalence, describing its nature,
and reporting seri ous causes. While valuable, these activities nonethe
less fail to address the prevailing problems: what are the common
causes, and what best should be done about them.
McKenzie does not provide a solut ion. For something t o be a soluti on
requires evidence of reliability, validity and effcacy These remain
lacking for neck pain and non-existent for thoracic spinal pain. The
text recognises that, but does refer to the small handful of studies
that have been undertaken.
What McKenzie does provide is an approach. In a feld where there is
no competit ion, where there is no proven method, one can argue that
any approach is not ionally val id. Its virtue is that it combats nihil ism
by giving reade rs a frm protocol to foll ow. This above all might be
the critical therapeutic ingredient.
To date, no studies have shown that this protocol is valid, i . e. that
the syndromes described really do exist and c or respond t o some
sort of verifed pathol ogy, be that structural or phYSiol ogical. Nor
has it been established that the specifcs of the protocol achieve
unique and superior outcomes. We do not know if derangement and
dysfunction mean anything more than idiopathic neck pain. We do
not know i f their specifc detection and treatment is any more effec
tive than comparatively arbi trary exercises to keep the neck moving.
Especially we do not know the extent to which patients respond and
beneft from confdent , convincing explanations and concerted care,
irrespective of content; yet it is that confdence that the McKenzie
prot ocol provides.
As readers and practitioners expl ore the McKenzie prot ocol , they
should remain open-minded. The prot ocol arms them with something
pragmatic to do, i.e. to get on with managing patients. It is highly
likely that they will meet with success suffCiently often to encourage
them to continue using the prot ocol ; yet they should not conclude
that this success is due to the specifcs of the protocol . Simply being
a good, caring practiti oner may be the active ingredient, not mastery
of a particular catechism of activity and intervention. Pract iti oners
should remain open to the possibili ty that it is the confdence and
care that they express that generates their results.
I
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Thi s uncertainty shoul d also be the prompt for McKenzie therapists
to catch up with the research agenda. They have no grounds for
c omplacency in thi s arena. They have produced a good deal of
research on lumbar spinal pain. It has not been matched for neck
pain or thoracic spinal pain. If the McKenzie prot ocol is to fll the
therapeutic vacuum for neck pain and thoracic spinal pain, it needs
the accompanying science t o demonstrate reliability, validity and
effcacy, which will promote it from a good idea to evidence-based
practice.
Nikolai Bogduk BSc (Med), MB,BS, MD, DSc, Dip Anat, Dip Pain Med, FAFRM,
FAFMM, FFPM (ANZCA)
Professor of Pain Medicine
University of Newcastle
Royal Newcastle Hospital
Newcastle, Australia
Acknowledgments
I would like to give special thanks to my co-author, friend and colleague,
Stephen May, MA, MCSp Dip MDT, MSc, who has willingly provided hi s
time and expertise t o make thi s second edition an evidence-based
text of importance t o all health professi onals involved in non-operative
care of the upper back and neck.
I am also great ly indebted to the many faculty of the McKenzie Institute
Internati onal who have either direct ly or indirectly influenced the
refnement s that have been made to the descriptions of the procedures
of assessment and examinati on. The value of these contribut ions i s
i mmeasurable.
I would also like to express my gratitude to Helen Clare, the I nstitutes
Director of Education, Kathy Hoyt and Grant Wat son, who gave so
much of their time to read the manuscript and provide invaluable
commentary and cri tici sm.
Finally, to Jan, my daughter, who has so well managed and coordinated
the vari ous specialists reqUired to successfully complete this maj or
task, 1 give my grateful thanks.
Robin McKenzie
Raumati Beach
New Zealand
April 2006
IVi i
viii I
About the Authors
Robin McKenzie was born in Auckland, New Zealand, in 1 93 1 and
graduated from the New Zealand School of Physi otherapy in 1952.
He commenced private practice in Wellington, New Zealand i n 1 953,
specialising i n the diagnosi s and treatment of spinal di sorders.
During the 1 960s, Robin McKenzie developed new concepts of diagnosis
and treatment derived from a systematic analysi s of patients with both
acute and chronic back problems. This system is now practi sed globally
by specialists in phYSi otherapy, medicine and chi ropractic.
The success of the McKenzie concepts of diagnosi s and treatment for
spinal problems has att racted interest from researchers worldwide.
The importance of the diagnostic system is now recognised and the
extent of the therapeutic effcacy of the McKenzie Method is subject
to ongoing inve stigation.
Robin McKenzie is an Honorary Life Member of the American Physical
Therapy Associati on "in recognition of distingui shed and meritorious
se rvice t o the art and science of physical therapy and t o the welfare
of mankind". He i s a member of the International Society for the
Study of the Lumbar Spine , a Fellow of the American Back Society, an
Honorary Fellow of the New Zealand Society of Physiotherapi st s , an
Honorary Life Member of the New Zealand Manipulative Therapist s
Associati on, and an Honorary Fellow of the Chartered Society of
PhYSi otherapist s in the United Kingdom. In the 1 990 Queens Bi rthday
Honours, he was made an Offce r of the Most Excellent Order of the
British Empire. In 1 993, he received an Honorary Doct orate from
the Russian Academy of Medical Science s. In the 2000 New Year's
Honours List, Her Majesty the Queen appointed Robin McKenzie as
a Compani on of the New Zealand Order of Merit.
In 2003, the University of Otago, in a j oint venture with the McKenzie
I nstitute lnternational, i nstituted a Post-graduate DiplomalMasters
programme endorsed in Mechanical Diagnosi s and The rapy. Robin
McKenzie has been made a Fellow in Physiotherapy at Otago and
lectures during the programme.
Robin McKenzie has authored four books: Treat Your Own Back;
Treat Your Own Neck; The Lumbar Spine: Mechanical Diagnosis &
Therapy; and The Cervical & Thoracic Spine: Mechanical Diagnosis
& Therapy (l st edition) and The Human Extremities: Mechanical
Diagnosis & Therapy.
Stephen May, M, MCSp Dip MDT, MSc, was born in Kent, England, in
1 958. Hi s frst degree was in English literature from Oxford Universit y
He trained to be a physiotherapist at Leeds and qualifed in 1 990.
Stephen worked for many years in a primary care musculoskeletal
physiotherapy clinic in the National Health Service in England. In
1 995 he completed the McKenzie I nstitute International Diploma
programme , and in 1 998 he completed an MSc in Health Services
Research and Technology Asse ssment at Sheffeld UniverSit y In 2002
he became a Senior Lecturer in Physiotherapy at Sheffeld Hallam
University
Stephen May i s author or co-author of a number of articles published
in international j ournal s, and he has previousl y collaborated with
Robin McKenzie on The Human Extremities: Mechanical Diagnosis
& Therapy (2000) and The Lumbar Spine: Mechanical DiagnOSiS &
Therapy (2nd edition 2003).
x
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Contents
CHAPTER ONE
CHAPTER TWO
CHAPTER THREE
CONTE NTS I xi
VOLUME ONE
Introduction ............. . . ......................... ... 1
The Problem of Neck Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . 5
Prevalence . . . . . . . . . . . . . . . . . . . . . . . . . .. .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Natural hist ory . . . . . . . . . . . . ......... ......... ................ .. .. 7
Severity and di sability. . . . . . . . . . . . . . . . . . . 8
Health care-seeking . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Ri sk factors . . . . . . . .... . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
OnseL . . .. . . . . . . . .. . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Prognostic fact ors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Cost . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Treatment effectiveness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Conclusi ons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Pain and Connective Tissue Properties . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... .. . . . . .. . . . . . . . . . . . . . ..... 17
Nociception and pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Sources of neck pain and cervical radicul opathy . . . . . . . . . . . . . . . . .. . . . . . . . 19
Types of pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Activation of nocicept ors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Mechanical nociception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... . . . . 28
Chemical nociception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Trauma a s a cause of pain . . . . . . . . . . . . . . . . . . . 30
Di stingui shing chemical and mechanical pain . . .. . . . . . . . . . . . . . . . . 30
Tissue repair process . . . . . . . . . . . . . . . 31
Failure t o remodel repair ti ssue . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . 37
Chronic pain states . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Conclusi ons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Cervical Anatomy, Ageing and Degeneration . . . . . . . . . . . . . . . . . . 45
Introducti on . . . . . . . . . . . . . . . . .. . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Cervical anatomy .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Vertebrobasi lar artery . . . . . . . . ... .. . . . .. . . . . .. . . . . .. . . . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . 47
Ageing and degenerati on . . . . . . . . . . . . . . . . . . . . . .
Morphol ogy, function and pathology . . . . . . ..... . . . ..... . . .
. . . . . . . . . . 48
. . 49
xii I CONTENTS
CHAPTER FOUR
CHAPTER FIVE
CHAPTER SIX
CHAPTER SEVEN
CHAPTER EIGHT
Cervical anatomy and the McKenzie conceptual model . . . . . . . . . . . . . . 50
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Movement and Biomechanics of the Cervical Spine . . . . . . 55
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Range of movement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Factors that affect the range of movement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . 56
Effect of posture on cervical spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Role of uncinate proce sse s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Effect of movement on st ructures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Upper cervical biomechanics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . 6 1
Sustained loading and creep . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Concl usions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Diagnosis and Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Seeking patho-anatomical diagnoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Classifcation systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Diagnostic triage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Sub-group identifcation - indications and contraindications
for MDT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Mechanical Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Derangement syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Dysfunction syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Postural syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Literature Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Effcacy studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Mechanically determined directional preference . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Centralisation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Reliabil ity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Prevalence of mechanical syndromes in neck pain patients . . . . . . . . . . 90
Conclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 91
Serious Spinal Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Int roduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Identifcat ion of serious spinal pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
CHAPTER NINE
CHAPTER TEN
CHAPTER
ELEVEN
CONTE NTS
I
xiii
Cancer/tumour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Horner's syndrome . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Spinal cord . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Fractures and di sl ocati ons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 04
Osteoporosi s. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 06
Spinal infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 08
Rheumat oid arthriti s (R). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 09
Ankyl osing spondyli t is . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1 0
Upper cervical instability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1 0
Extreme di zziness/vertigo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 12
Cervical spine and vertebrobasilar insuffciency (VBl) . . . . . . 1 1 3
Carotid artery pathol ogy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Conclusi ons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
Other Diagnostic and Management Considerations . . . . . 127
Introducti on . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
Cervical and thoracic zygapophyseal j oi nt pain . . . . . . . . . . . . . . . . . . . . . . . . . 128
Shoulder pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 33
Mechanically inconclusive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 35
Chronic pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . 1 36
Cervical spondyl osi s/stenosi s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 39
Cervical radiculopathy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 42
Surgery for cervical and thoracic problems . . . . . . . . . . . . . . . . . . . . . . . 1 46
Post - surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 48
Thoracic Outlet Syndrome . . . . . . . . . . . . 1 48
Conclusi ons . . . . . . . 1 52
The History ......... ................................................ . . . . . . . 1 53
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 53
Aims of hi st ory-taking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 54
Interview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 55
Patient demographics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 55
Symptoms thi s epi sode . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 57
Previous hist ory. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . 1 67
Specifc questi ons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 70
Physical Examination ........................................... . . . . . . 1 7 1
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 7 1
Aims of physical examinati on . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 73
Sitting posture and i t s effects on pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 73
Neurol ogical examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 76
xiv I CONTE NTS
CHAPTER
TWELVE
CHAPTER
THIRTEEN
CHAPTER
FOURTEEN
Examination of movement . . . .. ....... . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . 178
Repeated movements . . . . . . . . . . . . . . ..... . . . . . . . . . . . . . . 181
Repeated test movements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
Exploring frontal plane movements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
Static mechanical evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
Te sting inconcl usive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193
Other examination procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .194
Mechanical syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
Inconcl usive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196
Conclusi ons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
Evaluation of Clinical Presentations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
Introducti on . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
Symptomatic presentati on . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
Assessment of symptom response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204
Use of sympt om response to guide l oading strategy . . . . . . . . . . . . . . . . . 205
Mechanical presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
Assessment of the mechanical presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
Use of mechanical response to gUide l oading strategy . . . . . . . . . . . . . . . . 211
Sympt omatic and mechanical presentations t o identify
mechanical syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
Identifying responders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
Chronic pain - interpretati on of symptomatic re sponses . . . . 213
Conclusi ons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
Follow-up Evaluations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 7
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
Reaching a c onclusi on . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 7
Review process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 1
Conclusi ons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
Procedures of Mechanical Therapy for the Cervical
Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
Force progression . . . . . . . . . . . .. . . . . . . . . ...... .. ... . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . 224
Force alternatives. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226
Repeated movements or sustained postures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226
Application of the procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228
Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 9
CHAPTER
FIFTEEN
CHAPTER
SIXTEEN
CHAPTER
SEVENTEEN
CHAPTER
EIGHTEEN
CONTENTS I xv
Clinical Reasoning . ................ . .. .. 261
Introducti on . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
Clinical reasoning . . . ...... . . .... ...... .... ..... . . .... . . . . ....... . ....... . . . .. 262
Elements that inform the clinical reasoning process . . . . . . . . . . . . . . . . . . . 263
Data-gathering . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . ... . .. . . . ....... . .... 263
Know ledge base . . .. . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264
Clinical experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . ..... . . . . . . 265
Cognition and meta-cogni ti on . . . . . . . . .. . ... .. . . . . . . ... . . . . . . . . . . . . . . .. . . . . . . . . 265
Errors i n clinical reasoning . . . . . . . . . . . . . .. . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . 266
Clinician bias . . . .. . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .. . . . . . 267
Mechanical diagnosis and therapy and clinical reasoning . . . . . . . . . . . 267
Example of clinical reasoning proce ss . . . . . . . . . . . . . . . .. . . . . . . .. . . . . . . .. ... . . . . 269
Conclusi ons. . . . . . . . . . ..... ....... ..... . ................ . . ...... . .. . . ... . . . ...... 282
Recurrences and Prophylaxis . . . . ... . . . . ... . . . . ... . . . . . . . . . . . . .. . . . . . . . . 283
I ntroducti on . . . . . . . . . . . . . . . . .. . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . ... ... 283
Preventative strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . ... . . . . . 284
Future epi sode s . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . 285
Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286
Conclusi ons . . . .. . . . . . . . . . . .... . . . ... . . . . . . . . . . . ... . . . . . . . .. . . . . .... . . . . . . . . . . . . . . . . . . . . . . . 286
VOLUME TWO
Management of Derangement - Principles . . . . . . . . . . . . . . . .. . . 289
Introducti on . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . ... . . . . . . . 289
Stages of management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
Management principles . . . . . .. . . . . ... . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . 298
Treatment pathways in derangement . . . . . ................. ...... . . . . 307
Concl usi ons . . . . . . . . . . . . . . . . . . . . . . . . . ... . . ....... .. .......... 309
Management of Derangement - Central and Symmetrical
Symptoms (previously Derangements 1,2 and 7) . . . . . . . . . . . . . . 3 1 1
I ntroducti on . . . .. . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . ... . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 1 1
Extensi on principle . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 3 1 1
Deformi ty of kyphosis (previously Derangement 2) . . . . . . . ... . . . . . . . 3 1 6
Flexi on principle (previously Derangement 7) . . . . . . . 3 1 8
Conclusi ons. . . . . . . . . . . . . . . . . . ..................... .. . . . 3 1 9
xvi I
CONTENTS
CHAPTER
NINETEEN
CHAPTER
TWENTY
CHAPTER
TWENTY-ONE
CHAPTER
TWENTY-TWO
Management of Derangement - Unilateral and
Asymmetrical Symptoms to Elbow
(previously Derangements 3, 4 and 7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321
Introducti on . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321
Assessment - determining the appropriate strategy . . . . . . . . . . . . . . . . . . . . 322
Identifcati on of lateral component . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 328
Management - lateral component, no lateral deviation . . . . . . . . . . . . . 329
Management - lateral component, with lateral deviation,
wry neck or acute t orticollis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 332
Flexion principle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334
Conclusi ons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 336
Management of Derangements - Unilateral or
Asymmetrical Symptoms Below the Elbow
(previously Derangements 5 and 6) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339
Introducti on . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339
Differential diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 340
Determining the appropriate l oading strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343
Management when deformity is present . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 350
Non-responders t o mechanical diagnosis and therapy . . . . . . . . . . . . . . . 351
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 352
Cervical Dysfunction Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353
Introducti on . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353
Categories of dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 354
Pain mechanism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355
Clinical picture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 358
Physical examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 360
Management of dysfunction syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361
I nstructions t o all patients with dysfunction syndrome . . . . . . . . . . . . . . 363
Management of extension dysfuncti on. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 364
Management of flexi on dysfuncti on . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
Management of rotation dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 368
Management of lateral flexi on dysfuncti on . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369
Management of multiple direction dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . 370
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
Dysfunction of Adherent Nerve Root (ANR) . . . . . . . . . . . . . . . . . . 373
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373
Development of adherent nerve rooL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373
Clinical presentati on . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375
Hist ory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 376
CHAPTER
TWENTY-THREE
CHAPTER
TWENTY-FOUR
CHAPTER
TWENTY-FIVE
CONTENTS I xvii
Physical examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377
Upper limb tension test and differentiation of derangement
and ANR. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 378
Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 380
Procedure s for treating adherent nerve root . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381
Conclusi ons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 382
Postural Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383
Introducti on . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383
Pain mechanism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 384
Effect of posture on symptoms in normal population . . . . . . . . . . . . . . . . 385
Clinical picture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 387
Physical examinati on . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 388
Postures involved . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 390
Management of postural syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391
Postural syndrome - aggravating factor sitt ing . . . . . . . . . . . . . . . . . . . . . . . . . . . 392
Postural syndrome - aggravating fact or lying. . . . . . . . . . . . . . . . . . 397
Postural syndrome - aggravating factor standing . . . . . . . . . . . . . . . . . . . . . . . 398
Management of postural syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . 398
Consequences of postural neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 399
Conclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 400
Headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 401
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 401
Epidemiol ogy of headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 402
Causes of headache. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 403
Differential diagnosi s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 406
Cervicogenic headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 408
Neuroanat omy of cervicogenic headache and experimental
evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 409
Mechanical diagnosis and therapy and headaches. . . . . . . . . . . . . . . 41 0
Classifcation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411
Hi story . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 414
Physical examinati on . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1 5
Mechanical asse ssment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 416
Management of mechanical cervical headache . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1 7
Conclusi ons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 9
Cervical Trauma or Whiplash Associated Disorders . . . . . 42 1
Introducti on . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 1
What i s whiplash? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 422
Is whiplash reaP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423
xviii I CONTENTS
CHAPTER
TWENTY-SIX
CHAPTER
TWENTY-SEVEN
CHAPTER
TWENTY-EIGHT
CHAPTER
TWENTY-NINE
CHAPTER
THIRTY
Signs and symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . .. . 425
Classi fcati on of WAD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . 426
Natural hist ory . . . . .. . . . . . . . . . . . . . ... . .. .. . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427
Prognostic factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 428
Management of WAD - literature . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 429
Management - mechanical diagnosis and therapy . . . . . . . . . . . . . . . . . . . . . . 43 1
Conclusi ons . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 434
Thoracic Spine - Epidemiology, Pain, Anatomy,
Biomechanics . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 437
Introd uction . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . 437
Thoracic epidemi ol ogy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 437
Thoracic pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . 438
Thoracic anat omy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 440
Thoracic biomechanics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 441
Abnormal morphology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ... . . . . . . . . . . . . . . . . . 443
Conclusi ons . . . . . . . . . . . . . .. . . . . .. . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 445
Classification of Thoracic Spine Problems . . . . . . . . . . . . . . . . . . . . . 447
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 447
Seri ous thoracic spinal pathol ogy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 447
Mechanical syndromes . . . . . .. . . . .. . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 448
Other categories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . .. .. . . . . . . . . . . . . . 449
Scheuermann's disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. 450
Conclusions . . . . . . . ... . . . . . . . . . .. . . . . . . . .... . . .... . .. . . .. . ... . . .. . . . . ... .. .. . . 45 1
Thoracic Spine Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 453
Introducti on . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . .. . . . . . . . . 453
Hist ory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 454
Physical examinati on . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 456
Static mechanical evaluati on .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 461
Conclusi ons following the examination . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . 462
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 463
Procedures of Mechanical Therapy for the Thoracic
Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . .. . . . . . . . . . . . . . . . 465
Introducti on . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . .. . .. . . . . . 465
The procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . 465
Thoracic Derangement - Management.. . . . . . . . . . . . . . . . . . . . . . . . . 479
Introducti on . . . . . . . . . . . . . . . . . .. . .. . . .. . . . . . . . . .. . .. 479
Management of central and symmetrical symptoms . . . . . . . . . . . . . . . . 479
CHAPTER
THIRTY-ONE
CONTE NTS
I
xi x
Extensi on principle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 480
Patient review. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Management of asymmetrical and unilateral symptoms . . .
Extensi on principle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .
. . . 482
. . . 484
. . . 484
Lateral t reatment principle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 488
Conclusi ons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 489
Thoracic Dysfunction and Postural Syndrome -
Management........... .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 1
Introduction . . . . . . . . . . . . . . . . .. . . . . . . . . . . . .. . . . . . .. . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . 491
Dysfuncti on syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . ... .. 49 1
Postural syndrome . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . ... . . .. . .. . . . ... . .. . . . . . . . . . . . . . . 495
Conclusi ons .. . . . .. . . . . .. . . . .. . . . ... . . .. . .. . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 497
Appendix . . . .... . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . .. . . . . . .. . . . . . . . . . . 499
References . .. . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . 507
Glossary of Terms .......................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 545
Index .................................................. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 555
xx I
LI ST OF FI GURES
Li st of Figures
1 . 1 Severity and disability grading of neck pain eN = l l OO) . . . . . . 9
2 . 1 Patterns of referred pain produced by stimulating cervical
zygapophyseal j oints in normal individuals . . . . . . . . . . . . . . . . . . . . . . . 22
2.2 Patterns of referred pain produced by discography at
symptomatic levels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
2. 3 Cervical dermat omes derived by symptom provocation . . . . . 24
2. 4 Matching the stage of the conditi on t o management . . . . . . . . . . 37
3 . 1 Sketch of the adult cervical disc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 7
5 . 1 Initial management pathway - key categories, estimated
prevalence in neck pain populati on . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
6. 1 Classifcati on algorithm for cervical spine . . . . . . . . . . . . . . . . . . . . . . . . . 82
7 . 1 Pain intensity changes: 0 - 1 00 scale over weeks . . . . . . . . . . . . . . 85
7.2 Outcomes of whiplash: MDT versus standard
interventi on. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
7. 3 Effects of sustained flexi on and retracti on exercises on
cervical radiculopathy and controls eN = 23) . . . . . . . . . . . . . 88
7. 4 Centralisation of distal pain i n response t o repeated
movements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
7. 5 Classifcati on of 256 consecutive neck pain patients . . . . . . . . . 90
8 . 1 Canadian C-spine rules for radiography in alert and
stable patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 05
9. 1 Patterns of referred pain produced by stimulating
cervical zygapophyseal joints in normal individuals . . . . . . . . 129
1 1 . 1 Cervical derma t omes derived by symptom provocati on . . . 1 77
12. 1 Centralisation of distal pain in response t o repeated
movements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
1 7. 1 Derangement - management considerations . . . . . . . . . . . . . . . . . . . . 308
1 7 .2 Derangement treatment principles and symptoms . . . . . . . . . . . 309
25. 1 Outcomes of whiplash: MDT versus standard
interventi on . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 1
27. 1 Classifcation algorithm for thoracic spine . . . . . . . . . . . . . . . . . . . . . . 450
Li st of Tables
1 . 1 Prevalence of neck pain in general population studies . . . . . . . . . 6
1 . 2 Prevalence of persistent neck pain in general population . . . . . 8
2. 1 Basic pain types . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
2. 2 Key factors i n pain identifcation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 1
2. 3 Stages of healing - approximate timeframe . . . . . . . . . . . . . . . . . . . . . . . . 3 l
2. 4 Chronic pain states . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
2. 5 Characteristics of chronic pain syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . 39
2. 6 Pain-generating mechanisms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
5. 1 Typical signs and symptoms associated with nerve root
involvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 1
8.1 'Red flags' that may indicate serious pathology in neck
and thoracic pain patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
8.2 Signs and symptoms associated with spinal cord lesions
in the cervical and thoracic spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 04
8. 3 Suggested indicators for investigation following trauma . . 1 05
8. 4 Unexplained or new onset symptoms that may require
immediate medical attention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1 2
8. 5 Clinical features associated with vertebrobasilar
insuffciency or vertebral artery dissection . . . . . . . . . . . . . . . . . . . . . . . 1 1 6
8. 6 Differentiation between dizziness of cervical or other
origin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1 7
8. 7 Mechanical diagnosis and therapy and safeguards with
VEl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 24
8. 8 Physical examination screening tests for patients prior
to manipulation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2 5
9. 1 Intertester reliability of examination by palpation in the
cervical and thoracic spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 33
9. 2 Differential diagnosis of cervical and shoulder problems . . 1 34
9. 3 Characteristics of chronic pain syndrome . . . . . . . . . . . . . . . . . . . . . . . . 1 37
9. 4 Key [actors in identifcation of chronic pain state . . . . . . . . . . . . 1 38
9. 5 Reliability and validity of physical examination for
cervical radiculopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 45
1 0. 1 Symptom patterns relevant to management decisions . . . . . . 1 57
1 0. 2 Defnitions of acute, sub-acute and chronic . . . . . . . . . . . . . . . . . . . . . 1 59
LI ST OF TABLES I xxi
xxi i I
LI ST OF TAB L E S
1 0. 3 Criteria for defning status of condition . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 60
1 0. 4 Features of history ('red flags') that may indicate serious
spinal pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 69
1 1 . 1 Conducting a neurological examination . . . . . . . . . . . . . . . . . . . . . . . . . . 1 76
1 1 . 2 Typical signs and symptoms associated with nerve root
involvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 77
1 2 . 1 Dimensions of symptomatic presentation to monitor
progress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
1 2 . 2 Criteria by which paraesthesia may be improving . . . . . . . . . . . 203
1 2. 3 Traffic Light Guide t o symptom response before, during
and after repeated movement testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
1 2. 4 Di mensions of mechanical presentation by which to
assess change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20S
1 2. 5 Commonly used neck disability questionnaires . . . . . . . . . 2 1 1
1 2. 6 Mechanical responses t o loading strategy . . . . . . . . . . . . . . . . . . . . . 2 1 1
1 2 . 7 Characteristic symptomatic and mechanical presentations
of the mechanical syndromes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 1 2
1 3. 1 Different methods of clarifying symptom response . . . . . . . . . . 21 8
1 3. 2 Main elements of review process . . . . . 221
1 4. 1 Force progression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226
1 4. 2 Force alternatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226
14. 3 Treatment principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
1 4. 4 Procedures (not all in order of force progressions) . . . . . . . . . . 229
1 7 . 1 Stages o f management o f derangement . . . . . . . . . . . . . . . . . . . . . . . . . . 290
1 7. 2 Recovery of function - ensuring stability of
derangement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296
1 7. 3 Treatment principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
1 7. 4 Clues as t o need for extension principle (not all will be
present) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300
1 7. 5 Extension principle - force progressions and force
alternatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1 7. 6 Indications for consideration of lateral component .
1 7 . 7 Lateral deviation of cervical spine - defnitions . . . . .
1 7. S Clues as t o need for lateral principle (not all will be
present) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1 7. 9 Lateral principle - force progressions and force
. . . 302
. 303
304
. 304
alternatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
1 7 . 1 0 Clues as to need for flexion principl e (not all will be
present) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
1 7. 1 1 Flexion principle - force progressions and force
alternatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
1 7. 1 2 Clues to irreducible derangement (not all will be present) . . 307
1 9. 1 Response to extension forces in unilateral asymmetrical
symptoms and implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323
19. 2 Criteria for a relevant lateral deviation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333
20. 1 Clues to the differential diagnosis between derangement,
stenosis and adherent nerve root . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342
20. 2 Response to extension forces in unilateral or asymmetrical
symptoms and implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345
2 1 . 1 Articular dysfunction syndrome - criteria (all will apply) . . . 361
2 1 . 2 Instructions to patients with dysfunction syndrome . . . . . . . . 363
2 1 . 3 Recovery of function - ensuring stability of derangement . . 366
22. 1 Adherent nerve root - clinical presentation (all will apply) . . . 376
22. 2 Criteria defnition for adherent nerve root (all will apply) . . 380
23. 1 Postural syndrome - criteria (all will apply) . . . . . . . . . . . . . . . . . . . . . 389
23. 2 Management of postural syndrome . . . . . . . . . . . . . . . . . . . . . . 392
24. 1 Differential diagnosis of headache . . . . . . . . . . . . . . . . . . . . 403
24. 2 Possible ' red flag' indicators of serious pathology in
headaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 404
24. 3 Diagnostic criteria for migraine without aura and episodic
tension headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 406
24. 4 Possible clues to mechanical nature of cervicogenic
headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1 5
25. 1 Presenting signs and symptoms from whiplash . . . . . . . . . . . . . . . . 425
25. 2 QTF classifcation of WAD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 426
26. 1 Indicators of musculoskeletal cause of abdominal pain . . . 440
29. 1 Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 466
30. 1 Response to extension forces in unilateral asymmetrical
and implications . . . . . . . . . . . . . . . . . . . . . . . 485
3 1 . 1 Articular dysfunction syndrome - criteria (all will
apply) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 491
3 1 . 2 Instructions to patients with dysfunction syndrome . . . . . . . . 492
3 1 . 3 Postural syndrome - criteria (all wi l l apply) . . . . . . . . . . . . . . . . . . . . . . 495
3 1 . 4 Management of postural syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 496
LI ST OF TABLES I xxi i i
xiv
I
I ntroducti on
It is twenty-fve years since the frst book on the McKenzie Method,
The Lumbar Spi ne: Mechanical Diagnosis & Therapy, was published,
and over ffteen since the frst edition of this text described the system
as it applied to the cervical and thoracic spine. Much has changed
in the intervening quarter century in the world of spine care. It used
to be that clinicians, whether physical therapists, chiropractors or
osteopaths, dispensed treatments that included heat, electrotherapy
modalities, massage and manipulative therapy to mainly passive
patients for as many times as the clinician considered appropriate.
Manual therapists worked to whichever specifc model of j oint dys
function they adhered to, whether hypomobility, j oint fxations or
osteopathic lesions. The biopsychosocial model of pain had yet to
be born; the importance of patient involvement in management had
not yet been recognised and the term 'evidence-based health care'
was unknown. Before these terms became familiar to all, the system
of mechanical diagnosis and therapy provided a structured and logi
cal means of controlling mechanical spine pain that allowed patients
to be at the centre of management. This is still the case today, and
in the interim the evidence to support and vindicate the approach
continues to accumulate.
The second edition of The Cervical & Thoracic Spine: Mechani cal
Diagnosis & Therapy still presents the logical and structured
approach to the assessment, classifcation and management of neck
and trunk problems frst described in 1 990. The characteristics,
assessment , management and clinical reasoning associated with
the mechanical syndromes of derangement , dysfunct i on and
postural syndrome are described. As the recognition of serious spinal
pathology is important for safe practice, the limited literature available
that describes 'red flags' in the cervical and thoracic spine is presented.
The material has been thoroughly updated and expanded to include a
general introduction to neck pain problems that will be of relevance
to all who treat these patients. This includes a review of epidemiology,
pain, and relevant biomechanics and pathophYSiology. There are
contemporary and detailed reviews of headaches and whiplash,
detailing the usefulness and limitations of mechanical diagnosis and
therapy in these areas.
I NTRODUCTI ON 1 1
2 1 ' NTRODUCTI ON THE CE RVI CAL & THORACI C S P I NE: MECHAN I CAL DI AGNOS I S & THE RAPY
Research regarding lumbar spine problems is far more abundant than
that relating to the cervical spine, and this applies both to the general
literature as well as the literature relevant to mechanical diagnosis and
therapy. Nonetheless, there is increasing research into various aspects
relevant to neck pain, and the present volumes use this abundantly
However, it is important neither to take all research at face value nor
to slavishly accept all current research ideas.
There has been a recent t rend to emphasise the psychosocial
component of back and neck pain. The research into its evidence
base is extensive , but often fails to account for other important
prognostic factors such as centralisation; fails to account for studies in
which pain gets better and the psychosocial factors dissipate; fai ls to
determine if the psychosocial factors require treatment directed at
them; and fails to distinguish between different degrees of psychosocial
factors. Although psychological features of the spine pain experience
are important, these have rarely been examined in conj unction with
biomedical aspects. When they have, centralisation/non-centralsa
tion categories have been found to be more important predictors of
long-term outcome than fear-avoidance, depression, somatisation
and non-organic signs. Few trials have been conducted in which
classifcation system-based treatment has been compared to guideline
based treatment, but when this has been done targeted treatment has
demonstrated better outcomes than gUideline-led treatment. There
is much further research to be conducted, especially pertaining to
the cervical spine, but recent research continues to highlight the
relevance of centralisation and classifcation-led management for all
non-speCifc spinal patients.
Twenty-fve years ago, when The Lumbar Spine: Mechanical Diagnosis
& Therapy was published, it -presented a logical system of assessment
and management di rected at mechani cal syndromes wi th an
accompanying conceptual model. The concepts were extended to
include the cervical and thoracic spine in 1990 and the extremities
in 2000. With the updating of The Cervical & Thoracic Spine:
Mechanical Diagnosis & Therapy, the ongoing relevance of t hese
concepts in the 2 1st century is apparent. It provides a structured
system of exami nation and management of mechanical syndromes;
one t hat is patient-centred and indirectly affects the psychological
aspects of a spine pain episode; one that is alert to the epidemiological
aspects of spine pain as it emphasises sel f-management; and a
I NTRODUCTI ON
system that permits early recognition of non-responders and 'red flags'
when classifcation into a mechanical syndrome fails to be made. The
astonishing prescience of the system of mechanical diagnosis and
therapy is only truly recognisable in hindsight.
Robin McKenzi e
Stephen May
I NTRODUCTI ON 1 3
4 1 I NTRODUCTION THE CERVICAL & THORACIC SPI NE: MECHANICAL DIAGNOSI S & THERAPY
1: The Problem of Neck Pain
Introduction
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CHAPTER ONE Is
6 I CHAPTER ONE THE CERVICAL & THORACIC SPINE: MECHANICAL DIAGNOSIS & THERAPY
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Table 1.1 Prevalence of neck pain in general population
studies
Point/month 6m-ly* Lietime
Reference Country prevalence prevalence prevalence
Hasvold and Johnsen Norway 20%
1993
Makela et al. 1991 Finland 41% 71%
Bovim et al. 1994 Norway 34%
Cote et al. 1998 Canada 22% 67%
Lock et al. 1999 UK 21%
Leclerc et al. 1999 France 41%
Takala et aL 1982 Finland 17%
Westerhng and Jonssen Sweden 12% 18%
1980
Urwin et aL 1998 UK 16%
Picavet and Schouten Netherlands 21% 31%
2003
Bassols et al. 1999 Spain 22%
Linton et al. 1998 Sweden 44%
Hagen et al. 1997a Norway 15%
Cote et al. 2004 Canada 53%
Mean 21% 31% 69%
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THE PROBLEM OF NECK PAIN
Natural history
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CHAPTER ONE 17
8 I CHAPTER ONE THE CERVICAL & THORACIC SPINE: MECHANICAL DIAGNOSIS & THERAPY
Table 1.2 Prevalence of persistent neck pain in general
population
ReJerence Countr Neck pain Jar> 3 months
Andersson et al. 1993 Sweden 17%
30% (Neck-shoulder area)
Brattberg et al. 1989 Sweden 19%
Bergman et al. 2001 Sweden 19%
Picavet and Schouten Netherlands 14%
2003 36% (Neck, shoulders,
higher back)
Makela et al. 1991 Finland 11%
Hill et al. 2004 UK 48%*
Cote et al. 2004 Canada 47%
Guez et al. 2003 Sweden 18%
Mean 26%
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THE PROBLEM OF NECK PAIN
Figure l.1 Severity and disability grading of neck pain
(N = 1100)
600
500
400
'
.
300
E
i
200
100
o
o
Grade 0 no pain, no disability
Grade 1 low intensity, low disability
Grade 2 high intensityllow disability
Grade 3 high disabiity/moderately limiting
Grade 4 high disability/severely limiting
Source: COle et al. 1998
Health care-seeking
4
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CHAPTER ONE 19
10
I CHAPTER ON E THE CERVICAL & THORACIC SPINE: MECHANICAL DIAGNOSIS & THERAPY
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!cU !c cVaua!c UVUua s !ac!c:s ]|,sca aU ]s,c|cscca
vc-ca!cU ac!cs aU c-vc-ca!cU ac!c:s. ^cs! s!uUcs
aUUcss c, a !cv s ac!cs, c: c, cc !,]c c s !ac!c:, aU
Uc c! acccu! !c: c!|c !,]cs c s ac!cs ]|s cVc-Ia!cs !|c
cc c Va:acs cy ccsUccU aU :yccs Vaacs !|a! ac c!
:c!uUcU !|c aa,ss ^cs! s!uUcs ac ccss-scc!ca a!uc,
cccUy :s ac!c aU cu!ccnc |cc ]a) a! !|c sanc !nc ]|s
na, cVca a asscc:a!c c!vcc !|c acIc aU ]a, u! Uccs c!
ccn a causa . Ics]cc!:Vc s!uU, Ucsys ac ncc ccs!, aU
ccn]ca!cU, u! ca nc:c cca, cs!as| a causa ca!cs!] as
!|c, a:c ccUuc!cU a cc|c! ccvcU cVc !nc
lUVUua ac!cs asscca!cU v!| cc ]a ac cnac scx, ccasy
ayc u] !c acu! ' v|c !|c s Ucccs, aU |s!c, c ]cvcus
cc ]a /s acaU, c!cU !|c scc!c c a!ua |s!c, ]cVcus
cc ]a s a ]c!c! s ac!c c u!|c s,n]!cns cs]cca,
c: ]css!c! cc ]a |tcccc et al. 1999 Cc! et al. 21) Mcs!
s!uUcs c]c:! |y|c ]cVaccc a!cs c cc ]a vcnc !!a
nc |Vc et al. 2o Cc! et al. 21 tccc:c et al. I999 Cc!c et
al. 199c ^aca et al. 1991 HasVcU aU Jc|sc 199o /Ucssc
et al. l99o Vcs!c:y aUJcssc 19c). :cVca s!uUcs cuU !|c
]cVaccc c! cc ]a ccascs v!| ayc, a! cas! u! acu! '
!c ( ,cas c ayc a!c v|c| s,n]!cn c]c!y sccns !c Uccc
|HasVcU aU Jc|sc 199o ^aca et al. 1991 tcc et al. 1999
]aaa et al. 19c2 /Ucssc et al. 199o lanc 199). Vca
asscca!:cs |aVc cc cuU c!vcc snc:y, ccs!,, cv-]cssuc
]a !|cs|c!Us aU cc ]a |^aca et al. l991 Cc!c et al. 2
/Uc:sc et al. 22)
Ccnc!cs |aVc cc asscca!cU v:!| cc ]a, anc, c!|c: ]a
]:ccns suc| as |caUac|c |tcccc et al. 1999), una: ac ]a aU
]cVcus cc u:V |/Ucsc et al. 22 Cc! et al. 21) u! asc
Uycs!vc aU caU:cVascua ]ccns |Cc!c et al. 2) C!|c s!uUcs
asc suyycs! a asscca!c c!vcc cc ]a: aU ]a c!|c s!cs
|Vc et al. 2o Rcca et al. 1997 ljcna et al. 21).
:cnc s!uUcs Uc!cU ]s,c|cscca ac!cs !|a! ac asscca!cU v!|
cc ]a, u! na, s!uUcs |aVc !cuU c asscca!c |lcycs
et al. 199o /:cs et al. 1999 VyaU aU ac|cnsc 2).
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THE PROBLEM OF NECK PAIN
et al. 1 ^aca et al. l1 C:c!! et al. 21) la:ccv-lc:yV:s!
et al. lc) !cud s !ac!cs Va:cd c!vcc :c ad vc:c.
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scu!dc: sV:]!c:s. a:cys! vc:c :cc!cV ad cc!:c a! vc
Lcvc cduca!ca cVc cvc: c.sc|cd :cc:c ad ascd :a!ca
dc]:Va!:c: !ad scc asscca!c v:! cc ]a ^aca et al. 1 l.
Cc!c et al. 2 Vc et al. 2o) ]|cc vas c :ca!:cs] c!vcc
vc sa!:sac!c ad cc ]a u! |y| jc sa!s!ac!c |ad a ]c!cc-
!:Vc c!cc! tcccc et al. l) Hy ]c:ccVcd c dc:ads ad cv
scca su]]c:! a! vc vcc asscca!cd v! cc ]a .dcsc et al.
22 .:cs et al. 21a) ]|c a!!c vas a ]cs]cc!Vc s!.dV dcsy
!|a! adjus!cd !c: ]!Vs:ca ad d:Vd.a caac!cs!cs ad !|us |ad
a s!cy s!udV dcsy .cs et al. 21a). l a :!c-!cy ]cs]cc!Vc
s!.dV ]sVc|cscca !ac!cs cdccd vcc u:]c!a! ]:cd:c!cs
c! cc ]a as a adu! `a-Ju!.:a et al. l1)
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a!cd cc ]a: v!| vc s!a!c ]cs!ucs suc| as !V]:s!s V:sua
ds]aV vcc:s ad scvy :ac|:c c]ca!cs ccc et al. 1c
`yad ad ac|c:sc 2) HcaVc vc :c]c!!:Vc vc !ccc
ad cc hcxc |aVc cc asscca!cd v!| cc ]a ^aca et al.
ll .dcsc et al. 22) :cVc:a c!|c: s!.dcs |aVc !c.d a
asscc:a!:c c!vcc cc |cx:c ad cc ]a la!:yucs et al.
lcc lcu et al. 1c(. lya!.s et al. lo) :cVc s!ud:cs cccd
a! !c asscca!c c!vcc s:!!:y ad cc ]a !cu: !cud a vca
asscca!c ad !|cc !cud c sy!:ca! ca!cs:] .cs
et al. 1) lcvcVc a s!udV v!| a s!cy dcs:y a ]cs!:Vc
:dc]cdc! asscc:a!:c vas c.d c!vcc s:!!y ad cc ]a: ad
c!vcc cc |cxc ad cc ]a .cs et al. 2 l). 1s vas
a ]cs]cc!Vc s!.dV !a:y !c acccu! c!c cc!cudy ]Vs:ca
]sVccscc:a! ad :dVdua !ac!c:s
]vc s!.dcs |aVc cccd s]cc:!caV a! !ac!c:s asscc:a!cd v!|
]ca]scd ccV:ca :!cVc:!ca dsc dscasc lcscV et al. 1c+.
]csc et al. 1(). l:ccuc! caVV !!y cya:c!!c s:cy ad
d:Vy vc:c asscca!cd v!| !c daycss : cc s!.dV lcscV et al.
1c+) Jcsc et al. l() !cud !a! a :c cccu]a!:cs VcVy
]c!cssca dV:y ad a ccVa!cd :s c! cy cs]:!a:scd v!
]ca]scd cc:Vca !cVc:!ca d:sc
CHAPTER ON E 111
12 I CHAPTER ONE THE CERVICAL & THORACIC SPINE: MECHANICAL DIAGNOSIS & THERAPY
l! s cca !|a! !|cc ac a vdc ayc c! !ac!cs !|a! :aV c ]c!c!a
s !ac!cs !c !|c csc! c! cc ]a ]|c !ca!uc :s yccaV ]cc
uua!V :cs!V ccs:s!y c! ccss-scc!ca s!ud:cs !:c: v|c| a
causa c!vcc a !ac!c ad cc ]a cac! c cccudcd :c:c
|y|c-uua!V s!udcs v!| a ]:cs]cc!vc s!udV dcsy ad adjus!y
!c c!|c ]c!c!a ::s !ac!cs |avc cc ccduc!cd :cc :ccc!y
l! s cV !|a! ]|Vsca cad !ac!cs suc| as cc !cxc s!!y
ad s!a!c ]cs!ucs ad ]sVc|cscca !ac!cs a! vc ac :]c!a!
]cdc!cs c! cc ]a ]|c ]csc! !ca!uc vcud su]]c! ca:c
suyycs!cs !|a! ]ccycd s!!:y ad !cuuccV c! cc |cxc ac
]cds]csy !ac!cs !c cc ]a: ^clcz:c 1c1)
Onset
Cc::cV a suddc c sdcus csc! c! cc ]a s c]c!cd
^clczc 1c1 la:c 1U) 1|s vcud suyycs! !|a! c:a daV
:cc|aca cady :y|! !cuuc!V !yyc cc ]a sV:]!c:s
la:c |1U) c]c!s !|a! sV:]!c:s ac cuy|! c V ]ccycd
V]|c!c ]cs!uc du:y cady c dcsvc, V c!a!ca :cvc-
:c!s c sc ]a!:c!s c]c!, !c: s:!!y a da!I LuuaV sus!acd
cady du:y scc] :aV !:yyc: sV:]!c:s l a adc: ]c]ua!c-
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a: c cc ]a |cadac|c c cc s!!!css cda et aL 2UU2)
cc ]a ca asc c !yyccd V !au:a!c csc! :cs! cc::cV
v|]as|-!V]c jucs :cc C|a]!c 2' !c ccva! :a!ca Hcvcvc
! s ::]c:!a! !c ca :d !|c sdcus csc! c! :uc! cc ]a:
as !|s ac!s !|c c:ca !c :cc|aca cady !ac!cs !|a! :aV c
:]ca!cd ]:cds]csy, ]cc]!a!y ad ]:ccyy a ]a!:c!S
cc ]a
Prognostic factors
Icycs!c !ac!cs ac vaacs !|a! a!!cc! !|c cu!cc:c c! a c]scdc
c! cc ]a: ccc ! |as s!a!cd ]|c !ca!uc !|s aca s ::!cd
ad cvcvs c! !|c !c]c lc:y|cu!s et aL 1c .:cs et aL 1)
cV sx :ccva! s!udcs ycca!V c! ]cc: uua:!V vcc |cud
:cvca c]c!s vc:c cc!ad:c!cV acu! !|c c!!cc! c! ayc c ycdc c
cu!cc:c ad a: ]a ad ad:ccyca Hdys vcc c! asscca!cd
v!| ]cycs:s Hcvcvc, scvcc !:a ]a ad a |s!cV c! ]cv:cus
c]scdcs scc:cd !c :dca!c a vcsc cu!cc:c
THE PROBLEM OF NECK PAIN
:cvca ccc! ccc! s!uUcs avc Uc!:hcU !c:s !c: !c cc ]a
:s!c, aU cc:cU!:cs as ]cycs!:c !ac!cs Hy :!a ]a: aU
!uc!:ca Usa!, scccs cy Uua!:c c! cuc! c]scUc ]cvcus
c]scUcs c cc ]a cvc:cU vc-cy aU :!cU ]a!c! cx]cc!a-
!cs c! !:ca!:c! !avc ]cUc!cU ]ccc cu!cc:cs a! !vcvc :c!s
'ljc:a et al. 22). CUc ayc (> +) aU cccc:!a! cv ac
]a avc ]:cUc!cU a ]ccc cu!cc:c c! sc:!- aU cy-!c:
aU !:au:a, cy Uua!:c aU ]cvcus :s!c, c! cc ]a avc
]cU:c!cU ]ccc cu!cc:c cy-!c: ' Hcv:y et al. 2+). l a a:yc
]c]ua!:c s!uU, ca, cy! uUcU c]c!cU cc ]a: a! ascc
aU vcc !ccvcU !c: a ,ca vc +c' c]c!cU ccc ccuc!
c cc!ucus cc ]a: ' H et al. 2+). ::yhca! asc:c ca-
ac!c:s!cs !a! ]cUc!cU ]css!c! cc ]a: vcc cUc ayc (> +'
cs]cc:a!, +' !c ') cy c!! vc a! ascc cc:c:U ac ]a
aU c,cy as a cyua: ac!:v!,
Cost
l !c c!caUs !c !c!a ccs! c! cc ]a l( vas estimated
!c c I::(c( ::c 'lcycu!s et al. l) C! !s 2`' vas
s]c! c U::cc! :cUca ccs!s, :cs!, ],sca !c:a], vccas 77'
vas asc:cU , sccc!a c-:cUca ccs!s ]s cc:]acU !c a
cs!:a!cU ccs! c! I::+(c :c !c ac ]a !c c!c:aUs
l1 'va ]uUc et al. 1')
Treatment effectiveness
.s v! u:a ac ]a a vUc ayc c! !ca!:c! !cvc!cs
ac c!!ccU !c ]a!c!s v! cc ]a:. 1csc :!cvc!cs avc c!
a]]ca:cU !c a!!cc! !c uUc,y ]cvaccc c ccuccc a!cs
. u:c c! s,s!c:a!c cv:cvs avc cc uUc!ac !c cvaua!c
!c !:ca!:c! c!!cc!vccss c! :!cvc!cs !c cc ]a: aU !c
cccus:cs ac su::a:scU cc
LvUccc Uccs c! su]]c:! !c usc c! acu]uc!uc !c c:cc cc
]a:. c! cy! y-uua!, !:as hvc vc:c cya!:vc 'ljc:a et al.
1 V!c aU Ls! 1) :usccuc! !as avc Uc:cs!a!cU
sc!-!c: caycs ]a, u! cu!cc:cs c c!!c: !a sa:
!ca!:c! 'l:c et al. 21, 22) c c! c:ca!, syHca!,
c!!c !a ]accc 'V!c et al. 2+). Hy-cua:!, s!uU:cs Uc:c-
s!a!cU ac c! c!!cc! |c !ac!c 'ljc:a et al. 1 IaUc]a
C H A PTE R ON E 113
14 I CHAPTER ONE THE CERVICAL & THORACIC SPINE: MECHANICAL DIAGNOSIS & THERAPY
Iac 21). la!a cyady !|c usc c! u!ascud ]L: assayc
ccc!ca s!ua!c ad c!!c ccc!c!!ca]V cda!cs c |ca!
!|ca]V s c!!c acy :!cd c: ccc!:y I!adc]|a Iac
2 l lccy et al. 2').
/! ]csc! !|cc s !!c scc!hc cvdccc !c su]]c! !!c c||cc!vc-
css c| u!dsc]aV c]sVc|cscca c!a!a!:c ]cy:acs
lajaa:c et al. 21)
:cvc:a cvcvs |avc ]cvdcd !cd !c cdca!c su]]c! : |avcu:
c| !|c s!c!-!c cch!s c| c:sa!c auc a]ua!c lc
scc !V]cs c| cc ]a aU/c !cadac!cs /c: et al. 1( Hu:v!z et
al. 1( lca et al. l lc!c! et al. 2 l 2+). Hcvcvc
l: la:c 1) ccsdccd !|a! !|c !ca!u:c dccs c! dccs!a!c
!|a! !!c cch!s c| a]ua!c cu!vcy| !|c ss !!a! ac ivcvcd.
Rccc! cvcvs css et al. 222+) cccudcd !!a! a]ua!:c
aU/c c:sa!c |ad c c!!c c!|cc! !|a ]accc c: cc!:c ycu]s
ad vc:c cuua v|c cc]acd !c cac| c!|c u! dcc acc c:!!c
vcc cchca. Hcvcvc: v|c aua !|ca]V vas cc:cd v!|
cxc:c:sc csu!s vcc su]c:c !c cc!c ycu]s ]c c c! cca: cc|!
aua !|ca]V ! sccs us! c cc:cd v!| cxc:c:sc.
:cvca :cv:cvs !avc ccc!cd c !|c c||cc!vccss c| cxccscs |c
cc ]a ljca et al. 1 :a:y-la|a! 2`) ]|c I!adc]|a
Iac c Lvdccc-lascd C:ca I:ac!:cc udccs cccudcd
!!a! !!ca]cu!c cxccsc vas !|c cV :!cvc!:c v:!! ccaV
:]c:!a! cch!s :ca!vc !c a cc!c I!:adc]!a Iac 21)
V!c cxccsc !as cc cc]acd !c csa!c c: a:]ua!c
]us cxc:csc c!! ycu]s s|cvcd sa ]:cvcc!s css et
al. 2+). ]|s as! :cvcv "shows that it does not matter what hind
of passive treatment one offers, it is what the patient does that really
matters" `as-ayc ad 1c]]ca 2+).
Hcvy et al. 21) dc! hcd ad cxa:cd !vc!V- |vc :cvcvs
c! v|c| !vcvc vcc sVs!ca!c u! a !|csc vc:c |c !!c 1s.
Cccuscs accd ayccc! acu! csa!:c acu]uc!uc ad
d:uy !|c:a]V u! ayccd !|a! !|c cvdccc vas cccusvc c !!c
c||cc!vccss c| a]ua!:c ad !ac!c.
]|:s ::c| suaV c! !!c !ca!uc dcs]!c !s !a!cs vcud
suyycs! cc!a cccuscs acu! !|c aaycc! c| cc ]a !|a!
cccu v!! aaycc! yudccs acu! cv ac ]a: ]|c :ayc
THE PROBLEM OF NECK PAIN
c! ]ass:Vc !|c:a]cs c!!ccU !c :cc ]a: ]a!:c:!s :aV ]:cV:Uc sc:c
::!cU s|c:!-!c:: ]a: cc! a! cs! u! :cs! |aVc !acU !c Ucc:-
s!:a!c a:V usc!u c:y- c: cVc: sc:!-!c: c:ch! lc: a v:Uc :a:yc
c! ]assVc !c:a]cs s!: c:y Us]c:scU V c::ca:s c: a cyua:
as:s !|cc :s sca:! su]]c!Vc cV:Uc:cc
lc :c:c ac!Vc ca!:c:!s !|c cVUc:cc s :c:c ]cs!:Vc Lxcc:sc
a]]ca: !c c c!!cc:Vc. ^a:ua !c:a]V :aV c c!!cc!:Vc vc:
cc::cU v| cxccsc u! |as Uc:c:s!a!cU cc.a c: ]ccc cu!-
cc:cs vc: cc:]a:cU !c cxcc:sc ac:c
Conclusions
Cu .:Ucs!a:U:y c! !|c ]:cc: c! :cc ]a: :us! !cc!cc c
yuUcU V cc!a:: c!u!ac !.!s.
inflammation
tissue repair
remodelling
vertebrobasilar artery
ageing and degeneration
range of movement
factors that affect the range of movement
effect of posture on cervical spine
efficacy studies
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Source: Kjelltan and Oberg (2002)
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6 26 52
Secondary analysis of this trial involved objective measures of range of
movement and muscle endurance and strength (Kjellman and Oberg
2004) Although there were improvements in the other groups, only
the McKenzie group improved on all objective measures.
Rasmussen et al. (2001) reported on an uncontrolled cohort of sixty
patients with neck and arm pain, with many demonstrating signs and
symptoms of cervical radiculopathy that were followed-up at one year
after McKenzie evaluation and management. Of the forty-fve not
receiving compensation, thirty were much better, eleven somewhat
better, two were unchanged and two were lost to follow-up. Of the
ffteen receiving compensation, two were much better, one somewhat
better, nine were unchanged and three were worse. The differences
were highly signifcant, and the authors concluded that with a low
level of intervention after careful instruction, the McKenzie method
was effective for treatment of cervical radiculopathy in patients not
receiving compensation.
Regarding patients with symptoms from whiplash, early active move
ment augmented by mechanical diagnosis and therapy has been
shown to be effective (Rosenfeld et al. 2000, 2003). This study is
described in more detail in Chapter 25, but the results are presented
below (Figure 7.2).
CHAPTER SEVEN 185
86
1 CHAPTER SEVEN THE CERVICAL & THORACIC SPINE: MECHANICAL DIAGNOSIS & THERAPY
Figure 7.2 Outcomes of whiplash: MDT versus standard
intervention
50
45
8
40
35
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30
< 25
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The single effcacy study for non-specific neck pain published to
date, although it suggests superiority of mechanical diagnosis and
therapy over a control group, does not provide defnitive evidence of
treatment effcacy. Clearly more studies are needed in this area before
frm conclusions can be drawn.
MOChanCaIIydOlOrmInOddIrOClIonaI prOlOrOnCO
Mechanically determined directional preference describes the situation
when postures or movements in one direction centralise, abolish
or decrease symptoms and lead to an improvement in mechanical
presentation. Very often postures or movements in the opposite
direction cause symptoms and signs to worsen, although in part this
is a response to the length of exposure to the provocative loading.
The phenomenon of mechanically determined directional preference
is characteristic of derangement syndrome and helps to identify the
specifc directional exercise that will lead to the best management
strategy (Long et al. 2004). This study only involved patients with
back pain, but it is a key study in demonstrating the importance of
mechanically determined directional preference. It is proposed that
mechanically determined directional preference will present in a similar
way in patients with neck pain, although currently the evidence
is limited. At randomisation patients were allocated to exercises
that matched their mechanically determined directional preference
(extension responder did extension exercises, for instance), were
opposite to their mechanically determined directional preference
(extension responder did flexion exercises), or general exercises
LITERATURE REVIEW
and evidence-based active care. At two weeks in nearly all outcome
measures there were Significant differences favouring the matched
group. Over 90% reported themselves to be resolved or better, compared
to 24% in the opposite group and 42% in the evidence-based group
(Long et al. 2004).
Donelson et al. ( 1997) examined the pain response to repeated
end-range testing of sagittal plane movements in eighty-six patients
with neck and referred pain. Patients were randomised to perform
the movements in different orders, which did not affect responses.
In 45% of subjects, sagittal plane movements had consistent and
opposite effects. Of these, 67% improved with retraction and extension
and worsened with protrusion and flexion, and 33% improved with
protrusion and flexion and worsened with retraction and extension.
In another ten subjects ( 12%), both flexion and protrusion caused
peripheralisation of pain, but either decreased pain intensity, or
centralisation only occurred with retraction or extension rather
than both. Thus, in total 57% of this sample displayed mechanically
determined directional preference -in a single mechanical evaluation
limited to four sets of ten repetitions, which did not use overpressure,
mobilisation or frontal plane forces. In 43% of subjects there was an
increase in pain intensity or peripheralisation with lower cervical
flexion (ilexion and protrusion) and a decrease in pain intensity or
centralisation with extension and/or retraction.
Abdulwahab and Sabbahi (2000) investigated the effect of twenty
minutes of sustained flexion and twenty repeated retraction move
ments in thirteen patients with cervical radiculopathy and ten control
subjects. Flexion was mid-range as participants were simply asked to
read a magazine in their own relaxed style. Outcomes evaluated were
radicular pain intensity and the H-reflex amplitude as a measure of
compression of the nerve, with a decrease representing compression.
The H-reflex amplitude was Signifcantly decreased after fexion and
significantly increased after the retraction exercises. There was a
signifcant increase in symptoms following sustained flexion and a
Signifcant decrease follOwing retraction exercises in the radiculopathy
group (Figure 7. 3). Even the asymptomatic control group felt some
discomfort after the period of sustained fexion.
CHAPTER SEVEN 187
88 1 CHAPTER SEVEN THE CERVICAL & THORACIC SPINE: MECHANICAL DIAGNOSIS & THERAPY
Figure 7.3 Effects of sustained flexion and retraction exercises
on cervical radiculopathy and controls |N = 23)
5+-
8
4
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Source: Abdulwahab and Sabbahi 2000
COnlraI ISalIon
HCt tCJU)HP A|Ct IC\IJC\IOn5
Centralisation refers to the phenomenon by which distal limb pain
emanating [rom the spine is abolished in response to the deliberate
application of loading strategies (Figure 7.4). The phenomenon is
characteristic of derangement syndrome, and its high prevalence
rate, reliability of assessment and value as a prognostic indicator has
been established in a review (Aina et al. 2004). The review highlights
the limited documented evidence about centralisation in the cervical
spine.
Werneke et al. ( 1999) described the symptomatic responses o[ 289
patients, of whom 66 (23%) had neck pain. Centralisation was
strictly defned as clear-cut abolition during mechanical evaluation
that remained better and progressively improved at each session.
Another group, classifed as 'partial reduction', displayed gradual
improvement over time, but this was not necessarily progressive or
directly related to the treatment session. Similar p
rcentages in the
neck and back pain patients demonstrated centralisation (25% and
31 % respectively) and partial reduction (46% and 44% respectively).
There were no signifcant differences in outcome by pain site, so
back and neck pain patients were analysed together. Centralisers
averaged Signifcantly fewer visits (four) than the partial reduction and
non-centralisation groups (eight). However, there was no signifcant
difference in pain or functional outcome between centralisation and
partial reduction groups, which were both Signifcantly better than
the non-centralisation group.
LITERATURE EVIEW
Figure 7.4 Centralisation of distal pain in response to repeated
movements
HOIIabIIIly
When an examination procedure is being used to determine manage
ment strategies, it is important that it has good intertester reliability
to ensure that the procedure is consistently interpreted between
clinicians. If a procedure has poor reliability, it demonstrates that
clinicians cannot agree on how to interpret a particular fnding.
Unstable interpretations of physical examination fndings are likely to
lead to unsound and random clinical decisions about management.
Although reliability is widely considered an important aspect of any
examination process, deciding 'how much' reliability is enough is
unclear and controversial. Kappa values of 0. 4 have been accepted
(Seffnger et al. 2004), but values below 0. 5 have been said to indicate
poor levels of agreement (Altman 1991), and 0.75 has been deemed
a 'minimal requirement' (Streiner and Norman 2003).
Clare et al. (2004a) examined the reliability of ffty McKenzie
credentialed therapists in classifying ffty patients, twenty-fve each
cervical and lumbar, from McKenzie assessment forms. Results were
not separated for neck and back paper-based cases. Kappa value for
syndromes was 0.56 and for sub-syndromes was 0.68.
CHAPTER SEVEN 189
90 I CHAPTER SEVEN THE CERVICAL & THORACIC SPINE: MECHANICAL DIAGNOSIS & THERAPY
Clare et al. (2004c) examined reliability of assessment of fifty patients
by pairs of therapists, fourteen in total; half of the patients had neck
pain and half back pain. Prevalence of derangement was 88% / 84%,
dysfunction 0% / 4%, posture 0% / 0% and 'Other' 12% / 12%
for the two therapists. Kappa values for lumbar syndromes and
sub-syndromes were 1. 0 and 0. 89 and for cervical syndromes and
sub-syndromes 0.63 and 0. 84 respectively.
Dionne and Bybee (2003) videotaped twenty patients with neck pain
during a mechanical evaluation and then had ffty-four therapists at
varying levels of the mechanical diagnosis and therapy educational
programme view the videos and classify the patients. Reliability on
agreement for diagnosis was kappa 0.55, for sub-syndrome classif
cation was kappa 0.48 and for mechanically determined directional
preference was 0.45.
PrOvaIOnCOolmOChanICaISyndromOSInnOCkpaIn
palIOnlS
Two surveys have been conducted of consecutive patients seen by
McKenzie educational faculty (May 2004a, 2004b). In total, details
of over one thousand patients were included in the two surveys from
nearly eighty contributing faculty members, which included 256
patients with neck pain. The results were similar in the two studies,
with most neck pain patients being classifed as derangement (80%),
fewer numbers in other mechanical syndromes (8%, mostly dysfunc
tion) and some classifed as non-mechanical syndrome (12 %). The
minority of patients not receiving mechanical classifcation were
mostly classifed as mechanically inconclusive (4%), trauma (4%)
and chronic pain state (3%).
Figure 7.5 Classifcation of 256 consecutive neck pain patients
Ocun0cmcnI
OysIunctton
.. IustUrc
I ^u!ccnI ncrvcuu
|hcI
Source: May 2004a, 2004b
LITERATURE REVIEW
Of those patients classifed as derangement, the most common
reductive force was extension (66%), but 25% used some element of
the lateral treatment principle and 6% used flexion as the treatment
principle.
ConCIuSonS
This chapter has outlined the available evidence that is directly
relevant to the practice of mechanical diagnosis and therapy in the
cervical spine. The main point is that the evidence is limited and so
definitive conclusions about any aspect of the approach should be
made with caution. In general, only one or two studies are available
regarding any particular aspect; furthermore, a number of these studies
are only available as abstracts or articles that have not been published
in peer-reviewed journals. The evidence to date gives some support
for effcacy, reliability, the existence of centralisation and mechani
cally determined directional preference and a high prevalence rate of
mechanical syndromes in neck pain patients. However, further
research is needed to reach defnitive conclusions about all these
aspects of mechanical diagnosis and therapy in the cervical spine and
nothing at all has been published relevant to the thoracic spine.
CHAPTER SEVEN 191
921 CHAPTER SEVEN THE CERVICAL & THORACIC SPINE: MECHANICAL DIAGNOSIS & THERAPY
8: Serious Spinal Pathology
Introduction
The mechanical syndromes (McKenzie 1 98 1 , 1 990) that encompass
the majority of patients are described in other chapters. Most will
be classi
f
ed as derangement, with some dysfunction, and postural
syndrome classifcation only occasionally Only a small proportion of
patients are not classifed in one of the mechanical syndromes (May
2004b) . This includes a very few patients who have serious spinal
pathology, which is the subject of this chapter.
Wi thin specifc conditions that must be considered are the serious spinal
conditions that need early identifcation and referral to an appropriate
specialist. A brief description is given in the chapter of cervical and
thoracic myelopathy, fractures, tumours, spinal infection and other
conditions as examples of serious spinal pathology, which are absol ute
contraindicat ions for mechanical diagnosis and therapy Mention
is also made here of inflammatory arthropathies and osteoporosis,
conditions whose management may involve physiotherapy, but require
special consideration and appropriate diagnosis. The contentious
issues of vertebrobasilar artery insuffciency and cervical manipulative
therapy are also considered in this chapter.
During the initial assessment, an index of suspicion for serious spinal
pathology should be maintained, with the triage system (after Spitzer
et al. 1 987; CSAG 1994) being used:
serious spinal pathology
cervical radiculopathy
mechanical neck pain.
The incidence of serious spinal pathology may be less in the neck than
the back, where an incidence of 1 . 4% has been reported (McGuirk
et al. 2001 ) . In general, carcinomas and spinal infections affect the
cervical spine less than the other two spinal regions (Durr et al. 2002;
Narlawar et al. 2002) . In a survey of McKenzie Institute faculty of
over eight hundred patients, no 'red flag' conditions were reported
for neck pain patients, while there was a prevalence of 1 . 3% for back
and 6% for thoracic problems (May 2004b) .
CHAPTE R E I GHT /93
941 CHAPTE R E I GHT TH E CERVI CAL & THORACI C S PI N E: MECHAN I CAL DI AGNOS I S & TH ERAPY
Sections in the chapter are as follows:
cancer/tumour
Horner's syndrome
spinal cord
cervical
ankylosing spondylitis
upper cervical instability
extreme dizziness/vertigo
cervical spine and vertebrobasilar artery insuffciency (VEl)
background
testing protocol
dizziness
VEl test protocol
legal situation
mechanically inconclusive
chronic pain
symptomatic presentation
cervical radiculopathy
tests
surgery for cervical and thoracic problems
post -surgery
Thoracic Outlet Syndrome
tests.
Cervical and thoracic zygapophyseal joint pain
Zygapophyseal or facet joint painsomatic dysfunction is a common
diagnostic label used by manual therapists (Maitland 1986; Trott
2002; Gatterman 1998; McClune et al. 1998). This section explores
what is documented, rather than speculated, about this syndrome in
terms of diagnosis and treatment. Zygapophyseal joints are involved
in the normal ageing process of cervical spondylosis, but changes
such as anterior and posterior osteophytes, bony hypertrophy and
foraminal stenosis are commonly found in the asymptomatic popula
tion and thus are not intrinsically a source of symptoms (Gore et al.
1986; Friedenberg and Miller 1963; Teresi et al. 1987; Matsumoto
et al. 1998).
Much of the work done on this topic has been on individuals with
chronic whiplash symptoms, and mostly by the same team of
researchers. Pain patterns from different levels (C2 - 3 to C6 - 7)
were determined in fve asymptomatic volunteers by distending
the joint capsules under fluoroscopic control (Dwyer et al. 1990).
Distinguishable and characteristic patterns from each joint space
allowed the construction of a pain chart (Figure 9.1) A similar study
undertaken at the atlanto-occipital and lateral atlanto-axial joints
revealed a consistent pattern for the latter, but more variability for
the atlanto-OCCipital joint (Figure 9.1) (Dreyfuss et al. 1994b). The
validity of the frst pain chart was tested in a group of ten consecutive
patients with chronic cervical pain (Aprill et al. 1990). There was
virtually complete agreement between two observers regarding which
segmental level was involved from the patients' pain patterns, and
in nine out of ten cases this was validated by a positive response to
a zygapophyseal joint block at the appropriate level. These studies
OTH E R DI AGNOSTI C AND MANAGE ME NT CONS I DE RATIONS
revealed the zygapophyseal joints could be a source of pain, and
symptoms were in a consistent pattern of limited referral.
Figure 9.1 Patterns of referred pain produced by stimulating
cervical zygapophyseal joints in normal individuals
Source: Adapted from Dwyer eL al. 1990 and Dreyfuss et al. 1994b, with permission
A series of studies was undertaken to determine the prevalence of
cervical zygapophyseal pain in consecutive chronic whiplash patients.
These were done under image intensifer and either used two injections
to provoke and then relieve the patient's pain or double blocks with
different time-acting anaesthetics, or other strict inclusion criteria for
deciding if symptoms were from the zygapophyseal joints CBarnsley
et al. 1993a; Lord et al. 1996a). Such rigorous methodology and the
use of strict criteria are necessary as single cervical zygapophyseal
joint blocks have a false positive rate of 27% (95% confdence interval
15%, 38%), which disqualifes the validity of studies not using this
methodology CBarsley et al. 1993b).
In a total of over two hundred patients with chronic neck pain or
headache in fve separate studies (Bogduk and Marsland 1988;
Bogduk and Aprill 1993; Lord et al. 1994; Barnsley et al. 1995; Lord
et al. 1996a), the prevalence rate varied from 53% to 71 %, with a net
prevalence rate of 67%. Relief was achieved by injection at all levels
between C2 -3 and C6 - 7, but most commonly at C2 -3 and C5 - 6,
with C2 -3 joint being the source of OCCipital headaches. There were
no distinguishing features on history or examination that predicted a
positive response to injection (Lord et al. 1994, 1996a). For patients
with a headache emanating from C2 - 3, tenderness over the joint
was common, with a sensitivity of 85%, a positive likelihood ratio of
1. 7 and a negative likelihood ratio of 0.3 (Lord et al. 1994). In this
population if headache was the predominant complaint and tender
ness was present over C2 - 3, the positive likelihood ratio was 2: 1.
CHAPTE R NI N E 1129
130 I C H A PTE R N I N E THE CE RVI CAL & THORACI C SPI N E: MECHANI CAL DI AGNOS I S & THERAPY
In some of the studies carried out by this research group, discogenic
pain was also identifed. This was done by provocation discography
and either subsequent relief on anaesthetic or no pain on provocation
of two adjacent discs (Aprill and Bogduk 1992; Bogduk and Aprill
1993). In 310 patients who received discography (182), zygapophy
seal joint blocks (52) or both (76), discography was positive in 53%
and zygapophyseal joint block positive in 26%, of which 8% were
positive to both diagnostic tests (Aprill and Bogduk 1992). In a sub-set
of ffty-six patients from this population, 41 % had both a symptomatic
disc and zygapophyseal joint and only 17% had neither (Bogduk and
April! 1993). The authors maintained that either method, if used
in isolation, is inadequate in the diagnostic exploration of chronic
post-traumatic neck pain (Bogduk and Aprill 1993). Clearly both
intervertebral discs and zygapophyseal joints were commonly
symptomatic, often Simultaneously, in these groups of patients.
Thus, zygapophyseal joint pain has been found to be a very common
source of symptoms in chronic neck pain patients involved in
trauma, mostly post-whiplash, all attending tertiary care for further
investigations. Full demographiC data is not always given, but these
are mostly patients with very long histories of neck pain, measured
in years rather than months. There is some suggestion that they may
have been involved in more severe crashes, involVing higher impact
speed (Gibson et al. 2000). Although it is clear thal zygapophyseal
joint pain is common in this type of patient, this refers to a very
particular sub-group of neck pain patients and these fndings can
not be extrapolated to all neck pain patients. It is worth recalling at
this point the commonly dichotomous natural history of neck pain
follOwing whiplash - the majority get better in the frst two to three
months, and a minority have persistent and apparently irresolvable
symptoms (Chapter 25). It is probably this latter group that are being
investigated in these studies.
Another research group has investigated the prevalence of cervical and
thoracic zygapophyseal joint pain in several studies (Manchikanti et
al. 2002a, 2002b, 2002c, 2004). In fve hundred consecutive patients
presenting with chronic neck, thoracic or low back pain, diagnosis
was made using controlled comparative local anaesthetic blocks
(Manchikanti et al. 2004). The study confrmed hi.gh false-pOSitive
rates with Single blocks of 63% in the cervical spine and 55% in the
thoracic spine. Mean patient age was 47 years; mean duration of pain
OTH ER DI AGNOSTI C AND MANAG EMENT CONSIDE RATI ONS
was around eight years; nearly 50% had been involved in trauma; two
hundred had pain in more than one area; and all patients had failed
a range of conservative management. The double local anaesthetic
block provided a prevalence rate of zygapophyseal joint pain of 55%,
42% and 31 % respectively in the cervical, thoracic and lumbar spines.
Their other studies confrmed high false-positive responses to single
blocks, similar numbers reporting onset folloWing trauma, extremely
protracted episodes of neck pain, and similar prevalence levels of
cervical zygapophyseal joint pain (Manchikanti et al. 2002a, 2002b).
Similarly, in forty-six patients with chronic thoracic pain, symptoms
had been present [or an average of seven years, all patients had failed
conservative management, onset was following trauma in 39%, and
48% reported pain relief with double joint blocks (Manchikanti
et al. 2002c). A systematic review concluded that studies demonstrated
prevalence of zygapophyseal joint pain of between 54% and 67%
in the cervical spine and up to 48% in the thoracic spine (Boswell
et al. 2003a).
Apart from the obvious component from their history of very
persistent symptoms and a traumatic onset, the studies reviewed
above did not identify any other distinguishing clinical features,
except in one study when tenderness over C2 - C3 was associated
with a positive zygapophyseal joint (Lord et al. 1994). The validity
of manual diagnosis of cervical zygapophyseal joint pain has been
investigated in a small group of twenty consecutive patients Gull et
al. 1988). Neck pain had been present for at least twelve months,
but onset was not described, and fndings from manual palpation
were compared to radiologically controlled diagnostic nerve blocks.
Fifteen of the twenty were diagnosed as zygapophyseal joint pain,
and the manual therapist was 100% sensitive and 100% specifc in
diagnosis and segmental level. However, only one manual therapist
was evaluated, the study has not been replicated, and intertester
reliability needs to be established; therefore the study cannot be
said to vindicate manual therapy palpation techniques in general.
In a study Gull et al. 1997) evaluating intertester reliability to detect
painful upper cervical zygapophyseal joint problems, kappa values
were conSistently high for dichotomous deCiSion-making, but much
more varied when deciding on the symptomatic level, as detailed in
Table 9.1. However, of twenty volunteers without symptoms, three
were judged to have upper cervical joint dysfunction, indicating
problems with speCificity
CHAPTE N I NE 1131
1321 CHAPTE R N I NE TH E CE RVI CAL & THORACI C SPI N E: MECHANI CAL DI AGNOS I S & TH E RAPY
A number of studies have examined intertester reliability of a variety
of palpation techniques using kappa values. These have examined
localisation of tenderness or pain at segmental levels or nearby soft
tissues, judgements on passive intervertebral motion, diagnosis of
'fxations', or stiffness or joint dysfunction at segmental levels (Table
9.1). There is considerable variability in kappa values, from negative
values, which indicate reliability less than expected by chance, to 1.0,
which indicates perfect agreement. The rate of an acceptable kappa
value for clinical utility is still debated, but Altman (1991) suggests
that a value less than 0.5 indicates poor reliability. Out of over 160
clinical judgements made in these studies, only just over a quarter
have a kappa value greater than 0.5 - nearly half of these relate to
identifying painful levels or soft tissue. The ability of clinicians to use
palpation to detect joint dysfunctions, 'fxations', stiffness or other
passive intervertebral motion abnormalities in a reliable and consistent
is clearly unproven. If clinicians so commonly disagree about the
presence or absence of such clinical phenomena, their validity must
be open to doubt.
Finally, it is worthwhile to consider if there is clinical value in making
the diagnosis of cervical zygapophyseal joint pain; will the knowledge
of this diagnosis lead to a better outcome for the patient? Intra-articular
corticosteroid injections have been found to be no more effective than
intra-articular anaesthetic injection at providing lasting pain relief
Most patients' pain returned to near pre-injection levels within a few
days, and by about three weeks less than 20% of both groups had
pain less than 50% of pre-injection levels CBarsley et al. 1994b).
Percutaneous radio-frequency neurotomy produced relief of chronic
zygapophyseal joint pain at six months in seven of twelve patients
compared to one of twelve in the placebo-controlled local anaesthetic
injection group (Lord et al. 1996b). In the short -term this intervention
appeared to be effective for some, but its invasive and highly skilled
nature do not make it readily available to most patients.
In summary, cervical zygapophyseal joint pain does exist; the only
proven means of recognition requires a double joint injection block.
Using this technology, cervical zygapophyseal joint pain has been
found to exist in patients with very chronic neck pain of traumatic
and non-traumatic origin that generally has failed to improve with
conservative management. Reliable and valid identifcation by manual
palpation may be feasible, but is unproven. To date recognition of this
diagnostic category has not brought an effective means of treatment.
OTH E R DI AGNOSTI C AN D MANAGE ME NT CONS I DERATI ONS
Table 9.1 Intertester reliability of examination by palpation
in the cervical and thoracic spine
Ka
pp
a
Item Study Ka
pp
a * =/> 0.5**
Tenderness/pain Hubka and Phelan 1994 0.68
Strender et al. 1997 0.31-0.52 1/3
van SUijlekom et al. 0.0-0.87 8/17
2000
Bertilson et al. 2003 0.22-0.79 5/9
Levoska et al. 1993 0.15-0.62 4/8
Christensen et al. 2002 0.67-0.7 2/2
Horneij et al. 2002 0.12-0.49 0/4
Passive general
movement Fjellner et al. 1999 0.26-0.66 5/8
Fixations/stiffness/
joint dysfunction DeBoer et al. 1985 -0.03-0.45 0/8
Nansel et also 1989 0.013
Smedmark et al. 2000 0.28-0.43 0/4
Comeaux et al. 2001 0.12-0.56 Detail not
given
Fjellner et al. 1999 0.17-0.5 118
Jull et at. 1997 0.25-1.0 15/22
Passive intervertebral
motion Fjellner et at. 1999 -0.17 -0.49 0/58
Strender et al. 1997 0.06-0.15 0/3
Hanten et al. 2002 -0.07-0.86 4111
Christensen et at. 2002 0.22-0.24 0/2
Pool et al. 2004 -0.09-0.63 1/9
* range of kappa values or pooled kappa values
**number of clinical judgements with kappa value =1> 0. 5/total
number of relevant clinical judgements
Shoulder pain
Several studies have indicated that pain around the scapular and
shoulder region commonly arises from cervical disco genic or zyg
apophyseal joint disorders (Cloward 1959; Smith 1959; Whitecloud
and Seago 1987; Grubb and Kelly 2000; Dwyer et al. 1990; Aprill
et a1. l990) Stimulation of thoracic structures has also caused pain
in the chest and scapular region (Bogduk 2002c). Irritation by
hypertonic saline of the acromioclavicular joint (Ae]) and subacromial
space suggests that these structures may refer proximally, but that
CHAPTE R N I N E 1133
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1 CHAPTE R N I N E THE CERVI CAL & THORACI C S P I NE: MECHANI CAL DI AGNOS I S & TH E RAPY
predominantly symptoms are felt either around the AC or around the
shoulder respectively (Gerber et al. 1998). Differential diagnosis is an
important consideration when examining patients with symptoms in
the shoulder area. The link between cervical and shoulder problems
and the ability of cervical problems to mimic shoulder problems (van
der Windt et al. 1996; Hargreaves et al. 1989; Wells 1982; Schneider
1989) means that when pain is present at the shoulder, the source of
the symptoms must be conidered carefully Three scenarios might exist:
combination radiculopathy/myelopathy
The concern in this section is with somatic symptoms; cervical
radiculopathy is discussed in the next section, and myelopathy is
considered in the previous chapter. Somatic symptoms that stem
from degenerative changes may demonstrate a benefcial response to
repeated movements, and many patients with cervical derangement
also have cervical spondylosis on x-ray A not uncommon clinical
presentation in older patients with chronic symptoms is symmetrical
loss of rotation and lateral fexion and major loss of extension;
radiographs or such patients often display cervical spondylosis or
osteoarthritis. On mechanical evaluation, multiple direction dysfunction
is often demonstrated. Cervical dysfunction is considered in more
detail in Chapter 21, but in brief a global restriction of movement is
accompanied by end-range pain in multiple directions. Some such
patients respond in a few weeks to regular repeated movements;
however, some patients respond much more slowly The response is
often connected to the length of time symptoms have been present
and takes the form of increased range of movement with decreased
pain or increased range before pain or decrease of pain with same
range of movement.
CHAPTE R NI N E 1 1 41
1 421 CHAPTE R N I N E THE CE RVICAL & THORACI C S PI N E: MECHANICAL DIAGNOS I S & TH E RAPY
Cervical radiculopathy
Cervical radiculopathy is a specifc lesion affecting the cervical nerve
roots in which neck pain is accompanied by upper limb pain and
possibly neurological symptoms and signs (Radhakrishnan et al.
1 994) . This section presents some details about the epidemiology,
pathology and recognition of cervical radiculopathy For its manage
ment refer to Chapter 20, where it is included in the derangemen
category with referred arm pain below the elbow. The radiculopathy
is most often attributed to cervical disc herniation or spondylosis,
classifed often as soft or hard discs respectively (Wainner and Gill
2000; Radhakrishnan et al. 1 994) . However, it should be noted that
a number of case studies mention less common causes that include
serious spinal pathology, such as tumour and arteritis (Vargo and
Flood 1990; Sanchez et al. 1983; Wainner and Gill 2000) .
The prevalence of cervical radiculopathy has been estimated at 3. 3
cases per 1 000 population (Salemi et al. 1 996), and the peak incidence
is most commonly reported to occur between the third and fifth
decades of life (Wainner and Gill 2000; Radhakrishnan et al. 1 994).
The natural history of cervical radiculopathy appears to be generally
benign, but no prognostic or risk factors have been frmly established
(Wainner and Gill 2000) . Over time the resolution of pain is often,
although not always, accompanied by regression of the disc herniation
(Bush et al. 1 997; Maigne and Deligne 1 994; Mochida et al. 1 998) .
The nerve root is either irritated by bony osteophytes at the zyg
apophyseal or uncovertebral joints that are acquired secondary to
cervical spondylosis or by a cervical disc herniation. The disc her
niation is composed of mixed annulus or nucleus material, always
with a fragment of cartilaginous end-plate (Kokobun et al. 1 996).
In those coming to surgery, cervical disc herniations causing cervical
radiculopathy tend to be predominantly lateral (80 - 88%) with a
few that are paramedian ( 12 - 20%), compared to those causing
myelopathy, which are all median (36 - 40%) and paramedian (60
- 64%) (Kokobun and Tanaka 1 995; Yamazaki et al. 2003).
Distinction between bony stenosis and soft disc herniation as cause
for radicular symptoms may be important for prognosis, and perhaps
needs to be borne in mind for management. If foraminal stenosis is
the cause, an immediate and lasting benefcial response is unlikely
and radicular symptoms are likely to be aggravated by extension
OTH E R DI AGNOSTIC AND MANAGEMENT CONS I DE RATI ONS
that narrows the intervertebral foramen (Yoo e t al. 1992; Nuckley e t al.
2002; Farmer and Wisneski 1994). The same response may initially
occur if disc herniation is the cause, but multiple repetitions of
retraction and then extension may generate a positive response. The
foramina are also narrowed by ipsilateral rotation and lateral flexion
(Yoo et al. 1992; Nuckley et al. 2002), but again, with cervical disc
herniation, multiple repetitions of these movements may produce a
lasting change in symptoms.
Distinguishing bony stenosis from soft disc herniation as a cause for
radicular symptoms may not be straightforward. Both can present with
neck and arm pain in the dermatomal pattern, sensory and motor
defcit, reflex changes and restriction of movement. Both occur pre
dominantly at C5 - C6 and C6 - C7 segmental levels (between 70%
and 90%) Patients with soft disc herniations tend to be younger and
have shorter duration of symptoms, although these are relative rather
than absolute differences (Bertalanffy and Eggert 1988; Odom et al.
1958; Lunsford et al. 1980). In patients with bony stenosis spontaneous
improvement or resolution is less likely, aggravating factors will be
more consistent (extension, ipsilateral rotation and lateral flexion),
and flexion may temporarily decrease symptoms, whereas fexion
is likely to aggravate symptoms from a disc herniation. Ultimately
only a mechanical evaluation can determine if their symptoms will
respond to mechanical therapy, and it is likely that a number will not
respond. However, see section in Chapter 20 on 'Non-responders to
mechanical therapy'.
Tests
Clinical recognition of cervical radiculopathy has been made tradi
tionally by pain pattern and accompanying paraesthesia or muscle
weakness; some specifc provocation tests have also been described.
The radicular pain is severe and often obscures the neck pain, and
sensory loss or myotomal weakness tends to be variable (Aldrich
1990). However, there have been reports of much overlap in pain
pattern between those with clear neurological defcit and those without
(Dalton andJull1989). Groups with one or more neurological signs
were more likely to have pain in the forearm and hand, and more
likely to report these as the worst sites of pain, but these were relative,
not absolute di fferences.
The C6 and C7 nerve roots are most commonly affected, with
pathology at C5 - C6 and C6 - C7 motion segments respectively; the
C H A PTE R N I N E 1 1 43
144 1 CHAPTER N I NE THE CERVI CAL & THORACI C SP I NE: MECHANI CAL DI AGNOS I S & THERAPY
nerve roots of C8, C5 and C4 are less commonly affected (Aldrich
1 990; Wainner and Gill 2000; Radhakrishnan et al. 1 994) . Regard
ing cervical radicular pain patterns, there is considerable variation
between individuals, with no clear distinction between nerve roots
in their proximal pain pattern (Slipman et al. 1 998) . Research using
pain provocation has found common areas of referred pain distally:
C 4 is around the lateral neck and top of the shoulder; C5 is similar to
C4 but extends more distally to the lateral arm; C6 pain is distributed
down the lateral arm and into the thumb and index fnger; C7 is
similar to C6, but is usually more posterior and extends into the
middle and ring fngers (Slipman et al. 1 998).
A number of pain provocation tests have been described, with some
reporting of validity and reliability (Viikari-Juntura 1987; Viikari
Juntura et al. 1 989; Tong et al. 2002; Wainner et al. 2003) . Spurling's
test involves head compression in ipsilateral lateral flexion, or
compression in rotation and extension that provokes the patient's
radicular symptoms The shoulder abduction sign involves relief of
symptoms on plaCing the affected arm on the head, and the neck
distraction test involves pain relief on axial traction of the applied
though the occiput and chin. Tests for cervical radiculopathy have
been reviewed for their clinical utility (Malanga et ol. 2003; Wainner
and Gill 2000) .
Overall, reliability for many of the tests can be reasonable, but this
is not consistently so. Most of the tests have poor sensitivity except
the upper limb tension test, but this has low speCifCity and so will
be positive in many patients without cervical radiculopathy. High
sensitivity allows the diagnosis to be ruled out if the test is negative
(Sackett et a1. 1 997) . Most of the rest of the tests have good specifcity.
High specifcity allows the diagnosis to be ruled in if the test is positive
(Sackett et a1. 1 997) .
The best non-operative management for cervical radiculopathy has
not been determined. A plethora of treatments have been tried, and
although improvements are frequently reported, it is unclear if this is
a specifc treatment effect or simply a benign natural history at work
(Wainner and Gill 2000) . A number of problems mean the evidence
is very weak in this area; most importantly, randomised controlled
trials using homogenous groups of patients are rare.
OTHER DI AGNOSTI C AND MANAGEMENT CONS I DERATIONS
Table 9.5 Reli ability and validity of physical examination for
cervical radiculopathy
Physical
exami nati on item Rel i abi l i ty! Sensi ti vi ty Specifci ty
Spurling's Test 0.40-0.772 40-60%3 92-1 00%3
0.60-0.625 30%4 93%4
50%5 74-86%
Shoulder Abduction Sign 0. 21-.402 43-50%3 80-100%3
0.205 17%5 92%5
Neck Distraction Test 0.502 40-43%3 100%3
0.885 44%5 90%5
Dermatome sensation 0.41 -0.742 1 2-29%5 66-86%5
0. 16-0.675
Myotome testing 0.40-0.642 3-24%5 84-94%5
0.23-0.695
Reflex 0.735 3-24%5 93-95%5
ULTT 0.352 72-97%5 22-33%5
0.76-0.835
1 = kappa scores; ULTT = upper l i mb tension tests
Sources: 2 = Viikari-Juntura 1 987; 3 = Vii kari-Juntura et al. 1 989; 4 = Tong et al. 2002;
5 = Wainner et al. 2003
Epidural steroid injections are sometimes advocated for radiculopathy,
especially to avoid surgery (Boswell et al. 2003b). Again, positive
results are frequently reported in uncontrolled trials, although benefts
appear to be short-term and limited in the long-term. There appear to
be a lack of placebo controlled trials in a homogenous population with
established cervical radiculopathy (Wainner and Gill 2000; Boswell et
al. 2003b; Derby et al. 2004). When non-randomised observational
studies were considered as well, the conclusion was slightly more
positive (Abdi et al. 2005).
According to mechanical diagnosis and therapy diagnostic criteria,
cervical radiculopathy will mostly be classifed as derangement.
The value of posture correction and retraction exercises in cervical
radiculopathy has been demonstrated (Abdulwahab and Sabbahi
2000). Some patients respond to extension exercises, but a proportion
of these patients require lateral forces or unloaded forces to gain a
response. There will also be a group, those with more severe constant
radicular pain and constant neurological signs and symptoms, who
CHAPTE R N I N E 1145
1 46 1 CHAPTER N I N E THE CERVI CAL & THORACI C S P I NE: MECHAN I CAL DI AGNOS I S & TH ERAPY
will be unresponsive to conservative treatment - those with irreducible
derangements. Such patients will likely improve over time, but may
wish to consider surgery - see the next section. If the patient presents
with a two- to three-month history of cervical radiculopathy, which
has improved but is now intermittent and unchanging, the alternative
classifcation of adherent nerve root should be considered. For the
differential diagnosis and management of reducible derangement,
non-responders to mechanical therapy and adherent nerve root, see
Chapters 20 and 22.
Surgery for cervical and thoracic problems
Indications for cervical surgery are said to be instability, often secondary
to rheumatoid arthritis or trauma, radiculopathy, myelopathy and
tumour Uones 1998). In the thoracic spine, thoracic disc heriations
causing progressive myelopathy, trauma that may cause spinal cord
lesions, and progressive deformity that fails to respond to conservative
measures are said to be indications for surgery (Findlay and Eisenstein
2000) . If treatment is considered for thoracic scoliosis deformity, this
may be either conservative or surgical, with decisions for the latter
based on severity of the curve, rate of curve progression and skeletal
maturity of the patient (Findlay and Eisenstein 2000) .
The scientifc literature on surgery for neck pain and radiculopathy
consists mostly of uncontrolled case series with varying periods of
follow-up time (Carlsson and Nachemson 2000). Cervical radiculopathy
caused by nerve root compression from disc heriation or spondylosis
has been considered an indication [or surgery; however, there is no
clear validation for this assumption (Carlsson and Nachemson 2000).
Several prospective studies have in fact demonstrated the resolution
of cervical radiculopathy with time andor conservative management
(Bush et al. 1997; Mochida et al. 1998; Maigne and Deligne 1994;
Saal et al. 1996).
Only one randomised controlled comparison of surgery and conserva
tive management for chronic cervical radiculopathy was available in
the literature up to 2000 (Carlsson and Nachemson 2000; Fouyas et
al. 2002). Cervical radiculopathy had been present for at least three
months and the diagnosis was confrmed by MRI; there were twenty
seven patients in each of three groups: surgery, phYSiotherapy and
cervical collar (Persson et a1. l997a, 1997b; Persson and Lilja 2001 ) .
Physiotherapy consisted o[ an eclectic range of modal ities, manual
OTH E R DI AGNOSTI C AND MANAGEMENT CONS I DE R.ATI ONS
therapy and exercise distributed over ffteen sessions (Persson et al.
1997a). The surgery group demonstrated signifcant change after
treatment, and surgery and physiotherapy groups were both signif
cantly better than the collar group. At one year, however, there were
no signifcant differences between any of the groups. In effect all three
groups improved, but the surgery group had a qUicker improvement
in pain, function and other outcomes. However, all groups still had
moderate levels of pain at one year, and 29% of the surgery group
underwent additional surgery in the following year.
A prospective, multicentred study with independent review of patients
with cervical radiculopathy failed to find significant differences
between surgically and medically treated patients (Sampath et al.
1999). There was incomplete follow-up, but both groups showed
Signifcant improvements over time. A study in which surgical patients
were matched by gender and age with untreated patients reported
better outcomes in the surgery patients, but median pain rating was
little changed in both groups at nine months or two years (Lofgren
et al. 2003).
Regarding the value of surgery for other cervical spine conditions,
there were no randomised controlled trials evaluating surgery for
whiplash associated disorders (WAD) (Carlsson and Nachemson
2000). Even for patients with cervical myelopathy a conservative
approach to management has been demonstrated to be a viable option,
with outcomes as good as surgery in patients with mild to moderate
symptoms and shorter disease duration (Yoshimatsu et al. 2001;
Kadanka et al. 2002) In forty-nine patients with mild to moderate
cervical myelopathy, randomised to conservative or surgical treat
ment, there was no Signifcant difference between the two groups,
but no improvement over time, whereas twelve patients with severe
myelopathy showed Signifcant improvements after surgery (Bednarik
et al. 1999).
A Cochrane review on the role of surgery in cervical spondylotic
radiculomyelopathy found that the evidence was inadequate to
provide reliable conclusions on the balance of risk and beneft from
cervical spine surgery (Fouyas et al. 2002). Evidence for the value
of surgery in the treatment of neck pain and cervical radiculopathy
is largely absent, and with a few exceptions surgery for mechanical
disorders of the cervical spine is unnecessary (McKenzie 1990).
CHAPTER. NINE 1 1 47
1 48 1 CHAPTE R N I N E TH E CE RVI CAL & THORACI C S P I N E: MECHANI CAL DI AGNOS I S & TH E RAPY
Post-surgery
There is limited documented evidence about the best rehabilitation
approach following cervical surgery. The emphasis of examination
and management depends on when the patient is seen after surgery
and what type of surgery has been performed. There is much greater
variety of surgical procedures than at the lumbar spine. Cervical disc
herniations are commonly treated by microdiscectomy with or without
fusion, and instability or trauma by fusion and possibly fxation. Spinal
surgeons may have specifc protocols for post-surgery rehabilitation,
but post-surgical rehabilitation is often not requested. The surgical
approach is commonly anterior to reduce interference with muscles
and maintain posterior structure stability
Following microdiscectomy, the emphasis is on reassurance of the
patient, posture correction, gradual restoration of all movements and
progressive return to normal function. Movement should be regained
in a graded progressive fashion and neural mobility could be included.
For surgery that involves interbody fusion immobilisation is preferred
and generally phYSiotherapy avoided; for instance, prescription of
a cervical collar for two or three months post-operatively has been
suggested (Kokobun and Tanaka 1 995) . FollOwing fusion, end-range
movements should be avoided for up to three months, but lots of
mid-range movements may help to restore patient's confdence and
strengthen the fusion. It is to be expected that such patients will have
reduced range of movement.
Thoracic Outlet Syndrome
There is still controversy about the existence of Thoracic Outlet
Syndrome (TOS), mainly because of the lack of reliable and valid
diagnostic criteria (Rayan 1 998; Huang and Zager 2004) . Part of the
controversy lies in the fact that it is detected and treated by surgeons
more often in some countries than in others (Lindgren 1 993) . Whilst
not uncommon in the US, it is reported to be unknown in Australia
and seldom diagnosed in England and Europe (Lindgren 1 993;
Schenker and Kay 2001 ) . Reported incidence consequently varies
between three and eighty cases per thousand population (Huang and
Zager 2004) . TOS is a diagnosis by exclusion of all else.
By defnition TOS refers to the compression of the brachial plexus and
sub-clavian blood vessels at the apex of the thoracic cage (McKenzie
OTH E R DI AGNOSTI C AN D MANAG E ME NT CON S I DE RATI ONS
et al. 2004). Although compression is generally considered to be the
sale causative factor, in fact tension on the neurovascular bundle has
also been identified as a common cause of symptoms, which obviously
has implications for management (Ide et al. 2003). Symptoms are
variable but include pain, numbness, tingling andor weakness in
the arm and hand. TOS is usually classifed as either neurological or
vascular depending on the site of compression. True' neurological
TOS, about whose existence there is little controversy as signs and
symptoms are clear, is sometimes distinguished from 'disputed' TOS
because of the more subjective nature of the complaint in the latter
(McKenzie et al. 2004; Schenker and Kay 2001 ). Vascular TOS is
much less common and symptoms include Raynaud's phenomenon,
limb ischaemia, cyanosis, oedema in the hand and arm, and pallor.
With these symptoms there is less likelihood of diagnostic confusion
with cervical disorders and this description focuses on the neurological
category of TOS, over which diagnostic confusion is much more
likely
Compression of the brachial plexus or the vessels occurs as they pass
out of the thorax between the frst rib and the scalene muscles or the
clavicle, or between the rib cage and pectoralis minor (McKenzie et al.
2004; Rayan 1 998) . Predisposition to TOS may result from congenital
or acquired factors (Rayan 1 998). Cervical ribs, which may occur in up
to 1 % of the population, and first rib, vertebral or soft tissue anomalies
are all thought to be possible congenital predispOSing factors. Acquired
predisposing factors are said to be poor posture, repetitive upper limb
occupational stresses requiring work above shoulder level, hypertro
phic muscles in athletes and bony abnormalities. Sub-classifcation
of TOS based on the hypothesised site of compression is sometimes
recommended (McKenzie et al. 2004; Kreig 1 993) .
The signs and symptoms of TOS can be highly varied, with more
extreme clinical presentations in those with more advanced disease
(Rayan 1 998; McKenzie et al. 2004; Balci et al. 2003; Ide et al. 2003;
Schenker and Kay 2001; Huang and Zager 2004) . Those with the more
extreme presentation can show dramatic wasting of hand musculature
and other neurological signs, but often pain is not a key feature. In the
non-specific, more common type, pain is the main complaint; initially
there are symptoms of pain and paraesthesia, and later there may be
signs of numbness and muscle weakness as the condition progresses.
Onset is usually between 20 and 40, with a cervical rib usually the
CHAPTE R NI N E 1 1 49
1 50 I CHAPTE R NI N E
TH E CE RVI CAL & THORACI C S P I NE : MECHAN I CAL DI AGNOS I S & TH E RAPY
cause if incidence is younger; TOS is more common amongst women
than men. The patient often has poor posture and weak musculature.
Initially symptoms are provoked by raised arm activities, head rotation
or even taking a deep breath, but later they may be present at rest.
The symptoms are usually vague and diffuse, involving the whole of
the upper limb, the scapular region and the lateral neck; they can
be accompanied by headache and can be bilateral. The neurological
symptoms can be sensory or motor: paraesthesia, numbness, weakness,
clumsiness. Paraesthesia again may occur with raised arm activity but
later may be present at rest, and the neurological symptoms can be
radicular or diffuse in nature.
Tests
Various provocative diagnostic tests have been described to monitor
vascular integrity, but there is no absolutely rel iable and accurate
test to make a diagnosis of TOS (Rayan 1 998; McKenzie et al. 2004;
Mackinnon and Novak 2002) The various tests use provocative
positions whilst the radial pulse is monitored; however, as this is less
relevant to neurological TOS, it is accepted now that the provocative
pOSition may simply reproduce the patient's symptoms. In Adson's
manoeuvre the arm is by the side, the head tured to the affected
side, and the patient is instructed to inhale deeply. In the Halsted
manoeuvre or costoclavicular test the patient braces the shoulder
girdle down and backwards. In Wright's test the shoulders are
abducted 1 80 degrees, and in the hyperabduction test deep inhalation
is added to this. In Roo's or elevated arm stress test the patient elevates
the arms over halfway for three minutes whilst they open and close the
hands, and this is considered positive with reproduction of symptoms.
In the Cyriax Release test the shoulder girdle is passively elevated for
three minutes and a positive test occurs when paraesthesia, numbness
or pain is provoked (Brismee et al. 2004) . In obvious cases patients
simply raise their arms above the head and paraesthesia, numbness
or pain is rapidly provoked, and symptoms are unaffected by neck
movements.
The validity of the tests has been questioned because of false-posi
tive and false-negative responses (Brismee et al. 2004) . The tests are
commonly positive in the asymptomatic population (Plewa and
Delinger 1 998; Warrens and Heaton 1 987; Rayan and Jensen 1995;
Gergoudis and Barnes 1 980; Brismee et al. 2004). For instance, an
altered pulse has been found in 1 1 % to 60% (mean 29%) of volunteers
with different tests. Paraesthesia has been provoked in 2 % to 36%
OTH E R DI AGNOSTI C AND MANAGE ME NT CONS I DE RATI ONS
(mean 1 5%) of asymptomatic volunteers with different tests. Pain has
been provoked in 2 1 % of asymptomatic volunteers with Roo's test.
However, positive provocation tests, with elevated arms, have been
found in 94% of ffty patients diagnosed with TOS (Novak et al.
1 993) . The hyperabduction tests have shown good sensitivity, but
poor specificity; Adson's test has shown moderate sensitivity (79%)
and specifcity (76%) (Gillard et al. 2001 ) . When using multiple
tests there were modest gains in sensitivity and specifcity (Gillard et
al. 200 1 ) . Lowest false-positive rates were achieved with pain with
Adson's, costoclavicular manoeuvre, or any two shoulder manoeuvres
(Plewa and Delinger 1 998) .
Diagnosis of TOS therefore requires a staged process
diffuse neck/shoulder/arm symptoms of pain/paraesthesia
interview
patient demographics
age
occupationlleisure activities
functional disability
'red flags'.
Aims of history-taking
Using the form and the appropriate questioning technique at the end
of the history-taking, ideally the following will have been obtained:
neurological examination
examination of movement
protrusion
flexion
retraction
extension
repeated movements
protrusion (sitting)
retraction (sitting)
rotation (sitting)
flexion (sitting)
PHYS I CAL EXAMI NATI ON
testing inconclusive
other examination procedures
mechanical syndromes
derangement
dysfunction
postural
inconclusive.
Aims of physical examination
During the physical examination the following points should be
exposed:
usual posture
symptomatic response to posture correction
syndrome classifcation
Check symptoms:
deformity
It will then be known how regularly they have been doing their
exercises and if they are doing them correctly Their technique may
need correcting, but wait until you have heard how it affects their
symptoms. They may need encouragement to exercise more regularly,
or, less commonly, they might be doing too much. If patients are
having problems with the demands of a regular exercise routine, the
importance of doing it regularly needs to be emphasised.
The following questions and statements may help the patient to gain
more effective management:
'If you maintain the correct posture, can you keep yourself free
of pain?'
'If pain appears, note what you were doing immediately before.'
'If pain does appear, can you get rid of it by doing the
exercise(s)7'
Encouraging patients to 'problem solve' difficulties with the regime
or the exercise itself promotes self-management. Some patients are
reluctant to do things that hurt and are still very anxious about pain
responses. They need extra reassurance 'that hurt does not equal
harm', that reduced activty is only briefy benefcial at t he onset of
pain, and that the only way to try to re-establish normal [unction is
graded exposure to normal activity
FOLLOW-UP EVALUATIONS
Table 13.2 Main elements of review process
Mechanical therapy:
have they been exercising?
what exercises?
posture correction?
what is the response when they do them?
Symptomatic presentation:
site of pain
frequency
severity.
Mechanical presentation:
range of movement
deformity
quality of movement
function.
Implications
From the review you will also know their symptomatic and mechanical
response to performing exercises over a day or two - they will either
be better, worse or unchanged. As outlined in Chapter 12, this gives
a 'green light' for more of the same, a 'red light' or an 'amber light'
respectively. It is important to ensure that they are actually in these
states. Keen questioning and close analysis of symptomatic and
mechanical responses are sometimes necessary to elucidate the true
picture.
If better, nothing needs to be changed, only encouragement given and
the management strategy maintained unaltered. However, at some
point the direction or level of force of mechanical therapy may need to
be altered, especially if symptoms stop improving. Do not stick rigidly
with one loading strategy because of an initial improvement. If worse,
exercises and symptom responses need to be checked, but ensure the
patient is actually worse, rather than simply that the exercises 'hurt'.
When starting any unfamiliar exercise programme, new pains may
be generated; this is not unusual, but may confuse the patient. If they
are truly worse, the treatment principle or start position may need
to be changed; a derangement may be irreducible, or consideration
may need to be given to non-mechanical syndromes. If unchanged, is
the patient exercising regularly enough and doing the right exercise 7
If they have been, force progression may be necessary, or if this has
CHAPTER THIRTEEN 1221
222 1 CHAPTER TH I RTEEN THE CERVICAL & THORACIC SPINE: MECHANICAL DIAGNOSIS & THERAPY
been attempted already, an alternative treatment principle should be
considered. In the case of dysfunction no change would be expected,
and they should be encouraged to continue.
In essence, if the patient is better then the provisional diagnosis has
been confrmed. The original management strategy was correct, and
this should be continued unchanged. If the patient is genuinely worse,
a misclassifcation has occurred: either the patient has been categorised
in the wrong syndrome or they have been given the wrong treatment
principle. Sometimes the treatment principle may be right, but the
start position is wrong. In chronic symptoms there can be a temporary
exacerbation of symptoms when activation is started.
If the patient returns and after a thorough assessment of symptomatic
and mechanical presentations they are genuinely unchanged, then
further analysis is necessary. This takes the form of force progressions
until a change occurs. If symptoms start to reduce, abolish or centralise,
the directional preference is confirmed; if symptoms start to worsen
or peripheralise, an alternative direction must be explored.
Conclusions
In this chapter, the way the review process is carried out has been
presented. This is conducted at each session to determine if the
appropriate management strategy is being implemented. Depending
on the certainty of response, this will be done with more or less of the
detail presented here, but essentially the review involves enquiring
about the mechanical therapy component of management and about
their symptomatic and mechanical response.
14: Procedures of Mechanical
Therapy for the Cervical Spine
Introduction
This chapter contains general descriptions of the procedures that may
be needed in mechanical therapy of the cervical spine and indications
for their appl ication. The procedures described here include both
patient and clinician techniques.
In most situations patient techniques are used frst, and these are
frequently effective in resolving the problem without the need for
more interventions. Provided there is adequate instruction and careful
explanation regarding management of the problem, the self-treatment
concept can be successfully appl ied to most neck pain patients.
Patients with postural syndrome can only resolve their problem wi th
self-management strategies. Clinician interventions are ineffective
without the patient being educated about the role of posture as a
cause of their pain. In the dysfunction syndrome only the patient
is able to provide the appropriate loading strategies with suffcient
regularity LO enable a remodelling of the structural impairment .
Clinician techniques may aid this process, but on their own are
generally inadequate to resolve the tissue abnormality In the derange
ment syndrome the maj ority of patients can successfully manage their
own problem, while about 30% cannot recover with exercises alone
and need the addition of cl inician techniques (McKenzie 1 981 ) .
In general , patient techniques are always used frst and these are only
supplemented by clinician techniques when there is a failure to improve.
While the patient is improving with self-management strategies
there is absolutely no need to supplement treatment with additional
inLerventions that may encourage patient dependency
The essential philosophy of this method of management is to give
patients, whenever possible, knowledge and understanding of their
problem and the tools by which they can treat, manage and control
their own pain (McKenzie 1 981 , 1 990). To achieve this i t is necessary
to depart from the current traditional methods of treatment in which
the clinician applies passive modalities or manual procedures to
the paLient. From that approach the patient attributes his or her
recovery, rightly or wrongly, to what was done to them. Consequently
CHAPTER FOURTEEN 1223
2241
CHAPTER FOURTEEN THE CERVICAL & THORACIC SPINE: MECHANICAL DIAGNOSIS & THERAPY
dependency on the clinician develops and the patient returns for
assistance whenever problems recur. By avoiding the use of clinician
applied techni ques, unless absolutely necessary, and using primarily
patient- or self-generated techniques, the patient recognises that
they are capable of managing their own problem both now and in
the future.
However there are instances where force progressions involving
clinician techniques are needed. The role of force progressions and
force alternatives i n the elucidation of management strategies is
discussed. The therapeutic loading strategies that are used involve
posture correction, repeated movements and/or sustained postures.
Sections in this chapter are as follows:
force progression
force alternatives
Photos 49, 50: Overpressure is achieved by tbe weight ofthe upper {"unk sagging
against the resistance ofthe fingers (49). Further pressure is achieved by slight
rotation movements at end-range extension (50).
49 50
The rotary component described for previous procedures can now be
added while maintaining the prone posi tion. The upward pressure
from the outstretched fngertips against the underside of the chin
should be maintained as the rotation is commenced (Photo 50) . Thus
overpressure applies a gradual increase in the end-range loading.
CHAPTE R FOURTEEN 1241
I
Photo 48: From neutral bead
is mtracled, tben extended.
2421 CHAPTE R FOURTE E N THE CE RVICAL & THORACIC SPIN E: MECHANICAL DIAGNOSIS & THERAPY
Procedure 2b - Retraction and extension with rotation
and cl i ni ci an tracti on in supi ne
Photos 51,52,53: Longitudinal
trction (51) is/ollowed by
retrction (52), and then extension
(53).
51
52
53
The movement produced in this
procedure is retraction of the head
and extension of the cervical spine
while under traction appl ied by the
clinician.
The patient lies supine with Lhe
head and upper t runk over the
end of the t reatment table, unsup
ported down to the level of T3/4.
The clinician provides SUppOrL to
the patient's head by placing one
hand under the occiput with the
thumb to one side and the fngers
to the other side of the upper cervical
segments. The clinician then places
the other hand and fngers under
the patient's chin and gently but
steadily applies longitudinal trac
tion (Photo 51) . While maintaining
a frm traction, the clinician ful ly
retracts the patient's head and then
extends the cervical spine by draw
ing the head down to the end of the
available range of extension or as far
as the patient can tolerate (Photos
52 and 53).
The patient remains completely relaxed throughout the movement .
At the end-range of extension the traction forces are slowly but not
compleLely reduced, and the rotary component described in Procedure
2a is applied. While maintaining a little traction the clinician should,
in the fully extended position, rotate the head to alterate sides four
or fve times so that the nose moves only about one centimetre (half an
inch) to either side of the mid-line. During the performance of this motion,
the clinician attempts to obtain maximum end-range of extensi on.
The manoeuvre must be applied gentl y and sl owly for the first two or
three excursions. Throughout, there should be continuous monitoring
PROCEDURES OF MECHANICAL THERAPY FOR THE CERVICAL SPINE
of the patient's symptoms. Providing the patient's pain is reducing or
centralising or the range is improving, the procedure can usually be
repeated fve or six times in the frst session.
Appl icati on
Retraction and extension are essential components in the process of
reduction of posterior derangement. In patients with acute or severe
symptoms, persistent efforts to obtain improvement in the range of
retraction must be made before extension is appl ied or appropriate.
Retraction and extension are also important prophylactic exercises
for patients required to work in prol onged flexed postures. The
addition of the rotatory movement when in full extension increases
the range of extension, and may be useful in those with more resistant
derangements.
Procedure 2b is used for the reduction of posterior derangement in
the cervical spine, especially of the very acute or resistant posterior
derangement. It is particularly necessary for those patients whose
symptoms improve with earlier progreSSions but who do not remain
better as a result of their application. Sometimes it is the only way i n
which a posterior derangement may be reduced. Cervical extension
may be impossible until the clinician applies traction in this way.
The unloaded lying position allows a better range of extension than
can be obtained by performing this movement in either the sitting
or standing position. The degree of pain experienced by doing the
exercise in the unloaded supine lying position can be Signi fcantly
less in some patients. This is advantageous when treating patients
with acute symptoms who are unable, because of pain, to perform
the exercise in the sitting or standing positions. If the patient is able
to achieve total relaxation in the extended position, the weight of the
head provides overpressure.
The adoption of the alternative prone pOSition enables a greater
margin of patient control , and many who are apprehenSive about
performing this exercise in the supine position are readily able to
extend while prone.
Some patients are unable to tolerate retraction and etension, espeCially
when performed in supine, because oj dizziness or nausea. IJ this does
occur, an alternative position or procedure must be tested.
CHAPTER FOURTEEN 1243
2441 CHAPTER FOURTE EN
Photos 54, 55, 56: Extreme
ofpoor posture (54); extreme
josture co'r ction (55);
fOllowed b slight relaxation
(56).
THE CE RVICAL & THORACIC SPINE: MECHANICAL DI AGNOSIS & THERAPY
Procedure 3 - Postural correcti on
54 55 56
Slouch-overcorrect and posture correction
Sitting over the end or side of the treatment table, the patient is
instructed to adopt a relaxed slouched posture with the l umbar and
thoracic spine flexed and the head and neck protruded (Photo 54)
The patient then smoothly moves into the extreme of the erect sitting
posture with the l umbar spine in maximum l ordosis and the head
and chin maximally retracted (Photo 55) . Some clinician guidance
using gentle hand pressure on the patient's l umbar spine and chin
may assist in the learning process. The patient is then instructed to
relax back into the slouched position. This cycle should be repeated
ten times so that the patient moves from the extreme of the slouched
posture to the extreme o[ the upright extended and retracted posture.
After completing ten cycles of the procedure the patient shoul d hol d
"the extreme of the good position" for a second or two and then
release 10% of the strain (Photo 56). This is the posture the patient
must aim for on a daily basis. It is the learing process for maintaining
correct posture and is also therapeutic as some patients achieve
centralisation of their pain using this procedure alone.
Appl ication
Slouch-overcorrect is used to educate patients how to attain correct
posture and demonstrates to them the di fference between good and
bad postures. Patients are often unaware of their body posture, and
this procedure, practised regularly, helps them to become conscious of
their poor sitting habits. Once the patient is able to attain the correct
posture, they are then able to maintain the correction [or increasing
peri ods of ti me. As wel l as using sl ouch-overcorrect to retrain
postural ' habit' , done regularly i t is also a useful way of training and
PROCEDURES OF MECHAN I CAL THERAPY FOR THE CERVI CAL SPI NE
strengthening trunk muscles t o support the spine i n an upright
position. Maintaining correct posture is a strengthening process in
itself.
Lateral pri nci pl e
Al l lateral procedures are preceded by retraction.
Procedure 4 - Lateral flexion
Can be performed in sitting and supine.
57 58
Lateral flexion in sitting
clinical reasoning
data-gathering
knowledge base
clinical experience
clinician bias
preventative strategies
future episodes
evidence.
Preventative strategies
It is reasonable to advise patients about aspects of the epidemiology
of neck pain. Not everyone with neck pain has future episodes, but
a considerable proportion have future or persistent episodes. Warnings
regarding the natural history of neck pain, which is commonly episodic
or persistent, thus represent a responsible aspect of management. Most
patients are interested in prognosis and clinicians are responsible [or
proViding this information. Two main aspects should be discussed:
what can be done to try to prevent an episode and what can be done
should an episode occur.
Physical work factors have been shown to have a relationship with
neck pain, although not all studies are consistent in their fndings
(Ariens et al. 1999). Working in static postures, especially involving
neck flexion, sitting or driving, are biomechanical loads that have been
implicated as risk factors for neck pain in some studies (Grieco et al.
1998; Vingard and Nachemson 2000; Makela et al. 1991; Andersen
et al. 2002; Dartigues et al. 1988; Kilbom et al. 1986; Ignatius et al.
1993; Ariens et al. 2001b; Jensen et al. 1996). Of all the factors pre
disposing to neck pain, only postural stresses can be influenced and
controlled. This potential tool for prophylaxis and management must
be developed to the full. To this end, certain issues should be discussed
with the patient at several times during the treatment episode; it is
important that these issues are not left to the fnal session.
The following factors should be discussed using appropriate language:
most neck pain starts without trauma - use this [actor to high
light the insidious nature o[ onset and therefore the probable
relationship to ordinary daily and sustained postural stresses