Cervicogenic Dizziness – should you treat the upper trapezius?

Cervicogenic Dizziness, Cervical Vertigo


Simons and Travel 1999 describe myofascial pain (MP) as a common symptom usually caused by myofascial trigger points (MTrPs). The MTrPs in the neck muscles have been associated with a possible source of referred facial and cranial pain and could contribute to the nocioceptive activity occurring with Cervicogenic Dizziness.  The muscle most often affected with the presence of MTrPs in the neck region is the trapezius muscle,  specifically the upper fibers, and this is the most hyperalgesic muscle of the neck and shoulder (Sciotti et al 2001, Melegar & Krivickas 2007, Fischer 1987).  In fact, it is well established that treating soft tissue dysfunction of the upper trapezius is effective in the management of nonspecific cervical pain (Cagnie et al 2015,  Montañez-Aguilera FJ et al 2010Aguilera FJ et al 2009).

The authors of this manuscript consider addressing MTrPs in the descending fibers of the upper trapezius to be an appropriate treatment for individuals suffering from Cervicogenic Dizziness, however, it may be incomplete and suboptimal location to maximize potential outcomes.   It can have an influence on the functional relevance of the neck in its relationship with the cervico-collic reflex and vestibulo-collic reflex, but may not be a significant factor in modulation of its effects on head-in-space and head-on-trunk posture. All things considered, even though it is a popular location to stretch or treat manually, it may not be as much of a contributing factor of nocioceptive input into dysfunction of head on neck proprioception and self-motion perception.

The following two scenarios are the theoretical concepts to this impression:

  1. Relative Abundance of Muscle Spindles

Neck muscles are richly endowed with muscle spindles and contribute greatly to proprioception of the neck (Voss 1958, Cooper 1963, Kuklarni et al 2001Liu et al 2003).  The high muscle spindle density and the special features of the muscle spindles in the deep neck muscles allow not only great precision of movement but also adequate proprioceptive information needed both for control of head position and movements and for eye/ head movement coordination.

The number of muscle spindles in relation to muscle mass in a recent anatomical study by Banks RW 2006 confirms the greatest abundance is in axial muscles, including those concerned with head position.  The upper trapezius muscle is a high contributor of muscle spindles, but comparably, it is far behind suboccipital musculature, being rated #31 and along the same relative abundance as the adductor pollicis, extensor digitorum brevis, obliquees internus abdominus, omohyoideus, pronator quadratrus and extensor digitorum.  These muscles, due to their location, are of course not primary influence on head-on-neck proprioception.

So, based off of this information and overall thoughts on a patient’s adherence to a home program (keeping 5 exercises or less)— does stretching the upper trapezius, as described in the literature & pictured below, appear to be the most optimal treatment & one we should encourage with patients having cervicogenic dizziness?

Minguez-Zuazo, et al 2016, Malmström et al., 2007; Schenk et al., 2006; Wrisley et al., 2000

2. Influence based off of points of attachment on occiput (from Dvorak J. Manuelle Medizin. 1988)

points of attachment

Based off of the cross section of the occipital anatomy shown above, you can question the influence of the upper trapezius, as compared to suboccipital musculature, on the effect of head on neck posture/proprioception.  The surface area of the upper trapezius is significantly less than other muscles of the cervical spine, especially short dorsal musculature of the upper neck.  Therefore, we must take into account the overall influence of the upper trapezius compared to other musculature to optimize patient outcomes and results to improve pain, joint position error and postural stability.

Thus, the theoretical constructs and literature review for the non-articular management of cervicogenic dizziness is unclear and still under scrutiny.   The application of soft tissue management at one location vs another can be determined through a thorough clinical reasoning process and assessment  The type of soft tissue intervention that is most optimal (i.e. dry needling, ischaemic compression, IASTYM, dry cupping, deep massage, etc.) is still under debate, but the authors of this post do feel the location of your intervention can make a difference.

Sign up here for more information on Cervicogenic Dizziness!

You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the authors (husband–a manual therapist a wife—a vestibular specialist), teach a very unique course combining both the theory and practice of vestibular and manual principles in their 2-day course.  Pertinent to this blog post, the 2nd day includes the “Physio Blend”, a multi-faceted physiotherapist approach to the management of Cervicogenic Dizziness, which includes treatments of the articular and non-articular system of manual therapy and the most updated sensorimotor exercise regimen.

If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for prices and discounts.


Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Physical Therapist at In Touch Therapy, South Hill, VA

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Vestibular Physical Therapist at Drayer Neurological Clinic, Raleigh, NC





Would vascular testing trump + vertebral artery test in this case?

Screen Shot 2015-12-08 at 8.19.26 AM.pngI read with interest this Johnson et al 2008 Manual Therapy by Dr. Johnson on a patient responding to manual therapy after having a (modified) positive vertebral artery test.  This article is not open access but feel free to contact me if you would like it @ harrisonvaughanpt@gmail.com

The Case

The gist is a 24 year old female patient has a 1 year history of dizziness provoked by left cervical rotation and describes it as feeling of anxiety and difficulty communicating.

The clinician’s decision making prompted him to perform the modified vertebral artery test (VAT)—-which was negative to left—-but positive to right for concordant symptoms of dizziness/slow ability to communicate.

Therefore, he referred out for further investigation via duplex ultrasound—which was negative for any significant stenosis in carotids and vertebral arteries.

Considering the negative radiology report—he then proceeded to examine the cervical spine to identify other possible reasons for the symptomology—in this case, finding several tender points bilaterally in the upper trapezius, SCM, levator scapula and anterior scalene muscles.

Only strain-counterstrain techniques were performed—which resulted in a negative finding of modified VAT immediately, after several weeks and again at one year.


Overall, I think this is a great case to add to the literature on the limitations (false-positives) of the VAT and I appreciate the authors for taking the time to write it in a respected manual journal.

My big take home from this is :

  • from knowing the limitations behind the VAT,
  • a one year history of symptomology (it wasn’t stated in article why the patient finally sought care from physio—such as an exacerbation, etc)
  • — I wonder if clinical reasoning to refer out for duplex ultrasound due to positive VAT could be trumped by vascular testing (blood pressure, auscultation).

So my question to you is—

If this patient arrived to your clinic with the above symptomology and vascular examination unremarkable, in other words, blood pressure not elevated, negative bruits—-yes, this is a broad statement—

—-would you make the decision to proceed to a manual examination to confirm or refute your hypothesis that the symptomology is arising from a rotational vertebral artery dizziness condition PRIOR to having duplex ultrasound results?

Looking forward to hearing from you!  We can have more discussion in comment section.

Keep learning—Harrison


Case report=Standard PT and medical management fails…Osteopractic reigns.

This is a VERY powerful case report.  Read on to see how osteopractic intervention set the bar higher in physical therapy results.

Initial Evaluation

Subjective History: 42 y/o female presents with neck and arm pain.  It started when she was lifting heavy objects at work and at home due to circumstances of moving some things.  Her initial sensation was “her neck was caving in”.  She sought care from Dr. ***, who ordered MRI.  It showed herniations and then referred to PT for several weeks, then had 2 injections in neck— both helped some.  She was out of work for 6 weeks, but then returned to work and this aggravated her symptoms again resulting in another ESI in August and this helped for about 5 weeks too.  She also had a trigger point injection in upper trap after about 6 more weeks, but does not think that helped a whole lot.  She is returning to PT at this location as she still has headaches and (upper trap) pain that is constant, does not go away and is starting to change her as a person.

Date of Onset: 7 months ago.

Relieves symptoms: Nothing she can think of. She constantly is moving arm/shoulder. TENS unit helps while it is applied.

Location of Neck Pain: Initially, she had really intense headaches (that would reproduce with pressure points). However, the headaches are more subtle from occiput to frontal region L > R. Left side of neck around upper trapezius ridge.  She did have L UE symptoms but this improved after both ESI (it was described as burning, tingling, numbness). Pain is aggravated with the following activities or positions: Pretty much any activity, including housework, taking care of children, turning head both ways. Pain Quality: More achy and constant, as well as “knotted up”.

Pain Rating: 2/10 currently, 2/10 at best, 3/10 at worse ; but constant and never changes too much now.

Sleep Disturbance: Very difficult to lie on left side.  It wakes her 1-2x/night and now she sleeps on back or right side. She tried use of TR but started to irritate her.  She has a lordosis supported pillow, which seems to help.

Medication: Flexeril (takes at night for last 3 weeks & helps her sleep), constant use of ibuprofen (2 in morning and 2 in afternoon for past 2 weeks)

Cervical Active ROM
Cervical Extension AROM: 30 degrees

Cervical Flexion AROM: 50 degrees with pain at end-range

Cervical L. Lateral Flexion AROM: 25 degrees with pain at end-range

Cervical L. Rotation AROM: 80 degrees with pain at end-range

Cervical R. Lateral Flexion AROM: 25 degrees with pain at end-range

Cervical R. Rotation AROM: 80 degrees with pain at end-range

Neurological: 2+ B C5-C7. Negative Hoffman’s & Supinator Sign. Negative ULTT.

MMT: 5/5 all myotomes.

Palpatory findings: Hypomobilility through P/A and lateral glide testing of C0-1  & C1-2 on involved side (negative flexion-rotation test though).   Marked tenderness and familiar symptoms to ischaemic compression over mid-belly of upper trapezius, levator scapulae and scapula insertion at superior/medial border of levator scapulae.

Through speaking with patient about previous PT experience:

She received thoracic spine manipulation (mid-thoracic), cervical spine retraction, peri-scapula strengthening and cervical traction.

My treatment on 1st visit:

  1. Manual therapy
    • AA manipulation Bilaterally
    • Upper T/S “lift-off” Manipulation,
    • Mid-thoracic (T4-10) manipulation
  2. Exercise Prescription
    • Thoracic Spine Rotation in child’s pose position
    • Cervico-thoracic junction Extension over Foam Roll and Rolling Through T/S with Foam Roll

Immediate response at time of visit: 50% relief of all symptoms but still had pain at End-Range Cervical Rotation as described above.

Response in patient’s words at follow-up 2nd visit:

Patient reports she felt good after last visit.  However, yesterday her (upper trap) pain is back, and is the same.  However, no headaches.  The exercises give her relief, but only about 30 minutes.

My treatment on 2nd visit:

  1. Manual Therapy (Manipulation)
    • AA manipulation Bilaterally
    • Prone CTJ Manipulation Bilaterally
    • Mid-thoracic (T4-10) manipulation
  2. Dry Needling (could not perform on day 1 due to Virginia’s law of needing approval by physician)
    • Semi-standardized protocol for CGH per Dry Needling Institute
    • Additional point of levator scapula at insertion on scapula

Immediate response at time of visit in patient’s words:

I want to cry right now because I have not felt this good since my injury started

Response in patient’s words at follow-up visit:

I am doing fantastic.
That was the biggest relief I have had in 7 months.
It was the relief I have been looking for.
The exercises now are MORE effective and give her better relief at home.
For the first time this weekend, her husband and children told her that she didn’t complain about her neck/shoulder.

Take-home message from this case:

  • Firstly, the combination of manipulation and dry needling is powerful.  In this case, addition of dry needling at visit 2 resulted in marked improvements in headaches and localized upper trapezius symptoms.
  • Don’t just think that since symptoms are 7 months in duration that you can’t treat tissues locally and need some type of psychosocial component.  This individual was hurting and on her last leg. As noted in her expression at 3rd visit, her pain was affecting her relationship with her family. In this case, there was a constant barrage of C-fiber infiltration from the myogenic components of multiple muscles.  Stopping this can result in healing and change in pain.
  • I stated that standard PT had failed in the title.  Don’t get me wrong, it did help; but it was obvious for the patient that she needed something more.  It shows you that in the modern thought process of regional interdependence, we need to stay with our roots and treat locally too.  I would say go north (upper cervical spine) if typical treatments are not addressing this and you are not seeing results. Don’t lose sight of treating locally and thinking of just how the brain perceives input.
  • If you are a student or new therapist reading this, then if you run into a brick wall, go seek assistance from a mentor or someone with additional training.  See how they evaluate and treat an individual such as in this case.  Learn, reflect, and grow.
  • I also stated that medical management had failed too.  The ESI was the treatment that centralized upper extremity symptoms and obviously made an impact as we know the centralization phenomenon is prognostic.
  • The patient had a trigger point injection in the upper trapezius but no relief.  I wonder why? Was it because there was more involvement at the upper cervical spine and just treating the muscle did not help?  Or, was the levator scapula more of the pain generator?

What are you thoughts with this case?



2 years and 3 elbow injections, all for what?

I recently had this case:

Subjective History: 87 y/o female presents with right elbow pain.  It has going on 2 years or more.  She has had all of the injections should could have in the right elbow (at 3), and now she is told the elbow pain is from the neck.  She has also tried bracing and was treated by a physician for her wrist, which did not help (she was prescribed a wrist brace but it did nothing for her).  Sometimes the pain is so bad that she can’t stand it.  She said her hands can get numb too.  She is also trying to recover from shingles (had in February) that affected under the right arm and across chest.  She cannot elevate the right arm now due to pain from shingles.  She was seeing Dr. ***, who referred to Dr. ^^^.  The last injection that was given gave her relief for 2-3 months.

Relieves symptoms: hot shower.  She denies finding a comfortable position for arm when pain arises.

Location of Arm and Elbow Pain: Mostly in the right elbow but has pain all the way from shoulder to fingers on right side. Pain is aggravated with the following activities or positions: She does not know.  She said sometimes it just “hurts” and does complain of the fingers to get numb. Pain Quality: Dull and just hurts, almost to the point where she can’t stand it.

Pain rating: 5/10 currently, 0/10 at best, 10/10 at worse that can take 1-2 days to ease.

QuickDASH: 65%

Elbow: Full, pain-free elbow AROM and PROM

Cozen’s Test – Negative

Mill’s Test – Negative

3rd finger extension (ECRB) MMT: Negative (same with 2nd digit for ECRL)—negative for pain and weakness

Cervical Active ROM
Cervical Extension: 20 degrees, Cervical Flexion: 30 degrees with pulling at CTJ (no reproduction of concordant signs), Cervical L. Rotation: 40 degrees, Cervical R. Rotation ROM: 40 degrees

Technically you should put overpressure to ROM to rule-out the neck…but come on she was 87.

Shoulder Active ROM
Shoulder elevation Active Range of MotionL 70 degrees
**Patient says she has had trouble with shoulder elevation since shingles, which came on over a year after her current symptoms**

Considering lack of motion, I did not test functional rotation moments and only tested MMT in neutral by side (in 90/90 position):

Infraspinatus/teres minor: 4 /5
Weakness noted Bilaterally
Subscapularis: 4+ /5

Grip Strength:
R: 30#, L: 25#. No pain.

Note: marked TTP at lateral epicondyle but biggest finding==>Reproduction of concordant symptoms in elbow with ischaemic compression over the infraspinatus and teres minor.


Simple: Ischaemic compression with wiggle using middle phalanx for 20-30 seconds over infraspinatus and teres minor MTrP.  It reproduced symptoms initially but abolished them upon completion.  As taught by the Dry Needling Institute, the main MTrP for infraspinatus muscle is frequently 1/3 of the distance from the middle of the spine of the scapula along a line to the inferior angle of the scapula—so no need to push all around the shoulder—the Institute teaches you specifically where the highest percentage of pain generators are located. This could have been addressed with dry needling too, but unable to perform without MD order in VA. Exercise prescribed: S/L scapula retraction and S/L shoulder ER with towel roll.

Follow-up at 2nd visit:

Right UE symptoms STILL 0/10 but 2/10 at worse in last several days.

SOAP note Impression: Patient’s symptoms have been complex and very irritable for the last 2 years at least, with only short term relief from medical management.  From further assessment today, it appears patient’s symptoms are arising from shoulder girdle complex (see objective above) > cervical spine, but I do not see marked dysfunction of the right elbow (all negative lateral epicondylitis tests) other than tender to palpation at lateral epicondyle.  Considering she did not have symptoms today other than reproduction at MtRPs in the shoulder, we will continue to re-assess our treatment approach.  She is a good candidate for PT intervention.

Blog Impression: Basically no active or passive movement reproduced concordant symptoms (again did not put overpressure at joints but don’t typically for this age).  I was not satisfied with the medical diagnosis of lateral epicondylgia based on 1. Negative 3rd digit (ECRB) weakness and pain & 2. Negative pain and weakness with grip testing.  Only diagnostic sign was tenderness over the lateral epicondyle, which is not unusual for mostly anyone and did not give me any more clinical utility.  She has marked limitation in shoulder girdle function, which was interestingly limited after the onset of symptoms started 2 yrs ago.  I felt her symptoms (wooo nocioception coming from the shoulder) that referred into the upper extremity.  Now one thing I do not know is if she had positive lateral epicondylalgia tests that led to steroid injection initially.

Bottom line: Send to a physical therapist EARLIER in the care for a full musculoskeletal assessment.   A PT could have picked up symptom arising more proximal and actual lead to treatments to abolish symptoms, then a program to address the underlying dysfunction.  This patient could have avoided 3 cortizone injections and not lived with right upper extremity pain for 2 yrs with only relief in short duration by a hot shower.

My question to you’ll:

1. Why do you think the cortizone injection worked? What would be some of the mechanisms?  

2. What led me to the infraspinatus and teres minor muscles specifically?

3. Would you have treated more her cervical spine vs shoulder? Why or why not?

4. What other manual and/or exercise treatment would you have given for day 1?


Where and what is your DRIVER?


Photo courtesy: aaronshomeinspections.com

The title, “Where and what is your DRIVER”, refers to an area of the body where you think is the pain provocator, source of greatest dysfunction, locator of primary deficits, or in general the most common targeted area to intervene to get the most bang for your buck.  Now that is a run on sentence!

You can also call it the queen bee hive or the sweet spot.  Every therapist has one (or more), I want to hear yours!

This post is more open-ended questions & quick thoughts intended to get your feedback. Let’s start from the head and work our way caudally.

CV: The cranio-vertebral segment can be a prevalent source of dysfunction.  A decreased angle can lead to local neck pain, headaches, dizziness & possible caudal/distal complaints. From having too much upper cervical spine extension compressing the myriad of nerve roots exiting here to motor control deficits of anterior musculature, can this segment be the one?

Photo courtesy: joegambino.wordpress.com

AA: By far a commonplace of pain provocation, the C1-2 segment can be very unpleasant and misbehaves quite often.  It is the most cephalic source of rotation for the body and mostly agreed upon to be source of cervicogenic headaches.  A regular joint for manipulation by chiropractors and top breakout session with accompanying treatment if trained in SFMA.  The obliquus capitis inferior straddles this joint and can be a hot spot for soft tissue treatment by massage therapists, myofascial trained clinicians and dry needlers.

Photo courtesy: pt.ntu.edu

CTJ:  The top two choices above are almost always stemming from hypomobility and derangements at this problematic junction zone.  Can be nicknamed the Pembroke Pines of the spine, this multi-level (C7-T3 segments) is a rigid intersection worth addressing.   Surgeons want to avoid it but we certainly have many approaches to this hostile area.

Photo courtesy: functionalanatomyseminars.com

Scapulae: These girdles work marvelously individually and even together at a mathematically determined ratio with the brachium’s long bone.  Disruption in the firing patterns and postural position can alter how the upper quarter operates and can in turn affect the spine.  We can do so much more than shrug up and retraction down and in to address this area. The Romans thought the bone looked like a trowel, but is this your go-to tool?

Photo courtesy: wikimedia.org

Mid-thoracic spine: The most prominent segment of the spine posteriorly is at T4.  With our ADLs leading more towards a rounded and forward posture, is this level a considerable hazard?  Manual percussion often resonates adversely here and manipulation in this region usually ends with a Kelly Clarkson moment, but in a pain-relieving way.  Manipulation has a powerful effect here, especially due to its close proximity to the autonomic nervous system.

Photo courtesy: core-conditioning.com

Thoracic Ring (ribs): Linda-Joy (LJ) Lee may have hit the center of the universe here.  With the rib’s attachments to the spine posteriorly, the sternum anteriorly and a prime seat next to the diaphragm, the claim of treating this to improve optimal trunk and core function may have some substance behind it.  By encompassing a large percentage of the body, is this the ideal treatment zone?

Photo courtesy: ljlee.ca

Thoraco-lumbar junction:  Not a large threat in my opinion but can be the answer if other locations fail to achieve results.  Flared lower ribs and hyper-lordosis could create mayhem at this sector.

Photo courtesy: spineuniverse.com

SIJ (innominates): You know this could not be left out!  This is by far the site of the most polarizing opinions by clinicians in all fields.  It will be debated and researched until the sun doesn’t shine anymore. Sources show between 10-25% of the LBP arises from the SIJ, but is it 100% in your clinic?  Should we rely on well-documented provocation tests or is there an existence that just can’t be studied by research?

Photo courtesy: kypainmed.com

Hips: Connecting congruently with the innominates through a deep crater and site of concentric action anteriorly during the first steps of the gait cycle, how can it not get into trouble?  Weakness in the lateral/posterior structures has been demonstrated every month in JOSPT for the last 5 years to be related to just about every condition and controversy continues to exist for tightness in the IT Band and hip flexors.  Is there truth to all this madness?

Photo courtesy: thesportsphysiotherapist.com

Foot/Ankle Complex (FAC):  As soon as the feet hit the floor, dysfunction in the mingled array of bones and tendons that attach to almost every bone has to create dilemmas right?  Are we relying too much on orthotics, inserts and cushion shoes with our modern advances? Is this area becoming a light-weight that can’t handle forces anymore?  Is treating it just a gimmic or is there substantial certainty that this complex is the one?

Photo courtesy: workingperson.me

So where is your bread and butter intervention that gets maximal results?  Did your work-horse territory make the list above?  I didn’t include much soft tissue areas, what do the myofascial therapists think? Where IS  the underlying problem area? Or, IS THERE ONE? Is is like trying to find a needle in a haystack? Let’s hear (read) your feedback in discussion below.

Oh and if you haven’t already, vote In Touch PT Blog as Best Clinic Blog on Therapydia’s site.  It doesn’t take but a few minutes to sign up. Voting ends soon!


Busting the Myth that Manipulation is at End Range

I just recently wrote an article for MedBridge Education concerning a hot question: Is Manipulation at End Range?  You can access the link here.

I will say that I do recommend that any clinician who wishes to learn manipulation and provide it as an intervention get training from experts.  Even though I feel Medbridge has the best available online education on the web for physical therapists (and honestly can’t beat $200 for a whole year and at my last count, over 115 courses), learning the art of manipulation should be done under formal training with competency standards.

The whole article could be read on my site here, but I’m a physical therapist and not a HTML guy so having trouble with the videos on my site!

Hope you enjoy!


Premanipulative Hold: Survey Results

Several weeks ago, I placed a survey for all to provide their answer to whether or not a premanipulative hold is necessary prior to performing an OMT procedure to the cervical spine.  Thanks for everyone who participated!  Here are the results:


Interesting results in regards to 50% of the readers (half of the clinicians!) thought we should discontinue the pre-manipulative hold.  That is quite a response for our very conservative practice patterns.  How do these results compare to a similar study in 2004 in Manual Therapy??…see figure below:


This figure is taken off of an upcoming powerpoint slide for a lecture I’m teaching (reason for more bullet points).  But, quite different results!  My survey resulted in 50% of individuals endorsing discontinuing the pre-manipulative hold compared to only 12% in a prior survey.


-The comparison study surveyed Musculoskeletal physiotherapy members in Australia, had 419 responses and published in 2004.

-My survey only had 22 responses, was not limited to any country or additional training, and reported over 10 years later in 2013.

So, over the course of a decade, have we learned more about the pathophysiology of cervical artery dysfunction (CAD), more studies to show that we are less able to predict a dissection, and/or improved clinical reasoning through our subjective profiling??

You tell me!  I believe it is all 3 of the above.

Did you think the results would be as shown??

Pre-manipulative hold: a survey

As I prepare for a class in a few weeks on Cervical Artery Dysfunction (rather than just VBI), I am delving further into the research behind using a pre-manipulative hold prior to OMT to the cervical spine.  I would like to get feedback from readers of this blog (and others, so share!) to get an attitudinal survey of clinicians.

For a recap, the pre-manipulative hold test (cervical rotation test) is performed passively by a clinician to full end-range rotation, either sitting or supine.  The clinician is then to hold the positive for 10-15 seconds, back to mid-line for 30 seconds (for latent effects) and then test the contralateral side.  The test is performed with care and clinician continuously assesses for signs and symptoms.


It would also be beneficial to leave a quick reason behind your choice.  You can either do that in the survey section or down in comment section below.  Thanks!

Should you perform upper cervical spine instability tests?

With a 2:1 mentor program through my internship, I am able to get the students to work together on projects to better attain information, but to ask more questions and think outside the box than if taught individually.  Here is a recent case (albeit it is made up), that got them going to look up upper cervical spine instability test’s clinical utility.  I think they had fun and learned quite a bit. What would your argument be??


Patient is a 42 year old female who presents with neck pain.  Her symptoms started 5 years ago after she fell off of a horse.  She landed on her bottom and thinks she just “jarred” her neck.  After the incident, she went to the emergency room and had a full set of cervical spine radiographs, which were all unremarkable for a fracture.  Initial medical management was muscle relaxers and Naproxen (NSAID), which cleared up her symptoms after a few weeks.  The symptoms slowly came back on slowly over the years and finally went to her primary care physician for a check-up, which he recommended she try physical therapy and referred her to our clinic.  Her symptoms are predominantly on the right side of her upper cervical spine and radiating occassionally to the zygoma and retro-orbital on right eye.  This gives her headaches, which are daily in nature and last about an hour.  Pain rating is 8/10 at worse with her headaches and a constant 3/10.  Only relief is by taking an anti-inflammatory and lying down on her bed.  It gets worse the more she moves around at home to perform chores and sitting at the computer (she is a stay at home mom).  No other information from medical history or subjective questioning is remarkable.

You decided to perform an upper cervical spine mobilization (grade 4) to C1-2 in prone position.  After the treatment, patient reported having parasthesias in bilateral upper extremities going down to elbows, which you (as the therapist) attribute to soreness from lying prone for a sustained period of time as she has not been prone for many years (she sleeps on her back with 2 pillows since the accident).  Patient calls back leaving a message on office voicemail that night of the treatment saying she was going to the emergency room as her symptoms are worse and she is continuing to have worsening symptoms into the bilateral upper extremities.  She was referred to emergency surgery after having a MRI due to on-call neurologist clinically diagnosing her as having upper cervical spine instability and had emergency surgery to stabilize this area through a fusion.

Several months later, you receive a summon for court as this patient is sueing you for negligence as she had to have surgery since your intervention.

Your task as prosecutor is to cite evidence based on this case that the therapist should have performed upper cervical spine instability tests prior to manual treatment to prevent this injury.

 Your task as the defense attorney is to cite evidence based on this case to defend the therapist saying this could not have been avoided.

Good luck!

The analgesic effect of deep cervical flexor strengthening: Part 1

As manual therapists, our major goal of treatment is to provide a pain modulating effect for our neck pain patients.  This is usually done through either mobilization/manipulation, soft tissue releases, modalities, repeated movements in a direction of preference, etc.  I have historically not performed any type of exercise (other than repeated movements) for the deep cervical flexors until the pain has been more under control.  However, I do on occasion implement upper deep cervical spine flexor endurance training (longus colli, longus capitis) initially if I find this to be a significant impairment.  You can review back to a past article here (actually my first blog post on my site!) in Aug 2009 here to get further information on this topic.

I have done this through my own cause and effect patterns and assess/re-assess model over the years but finally came across a research article by O’Leary and colleagues in the Journal of Pain here to put evidence into my clinical thinking.  This study looked at the difference in immediate pain relief locally and systemic effects in another location by randomizing into either a cranio-cervical flexion coordination (CCF) exercise group, control group or cervical flexion (CF) endurance group.  The looked at systematic nervous system function, pain pressure threshold (PPT), thermal pain threshold at the local and distal site, as well as recorded the visual analog scale at rest and with cervical movement.  The main positive finding from this study was:

Immediately after 1 session of exercise, there was a

reasonably sized increase of 21% (P < .001, d 0.88) and 7.3% (P .03, d 0.47) in PPT locally at the

neck for the CCF exercise and the CF exercise, respectively.

Here is the graph for the findings:

O'Leary 2007
O’Leary 2007


In short, this study showed that pain pressure threshold of the involved segments (as initially examined from a clinician…in this case 85% at C2-3), decreased significantly mainly in the cranio-cervical flexion coordination exercise group.  One of the cause-effect from a manual treatment is assessing this pain-pressure threshold too, but just after a passive approach instead of an active approach. There was an immediate hypoalgesic effect of exercise, similar to what we can get from manual therapy.  It is a very effective way to improving carry-over from your treatment (as in prescribing it for home) to continue to get pain-relieving results.

Stay tuned for 2nd post on how I get the upper cervical deep flexors to activate.