Edwards (1992) and Maitland (2005) recommend that palpation of the upper cervical spine should be used to confirm the findings of the active range of movement and passive physiological range of movement assessment. They also suggests that palpation should be combined with movements to enhance structural differentiation. Below is an example of this structural differentiation.

"There is another particularly important test procedure that is used when it is necessary to determine whether a patient's symptoms arise from a disorder of the C2-3 apophyseal joint or the C1-2 apophyseal joint. With the patient prone and the head in the neutral position, poster-anterior pressures are applied, for example, to the left articular pillar of C2 so as to move it in a poster-anterior direction. The quality and range of movement, and the accompanying pain response, are compared with the same features when the postero-anterior pressure is applied with the same strength to C2, but this time with the patient's head rotated approximately 30-40 degrees to the left. If the pain response is greater with the head rotated than it is with the head straight, the disorder is at the C1-2 joint. If the pain response is greater with the head straight, then the disorder is at the C2-3 joint." (Maitland., 2005, p. 259).

Founder of the Watson Headache Clinic and Institute, Dean Watson, has presented a similar framework. Watson's primary objective is the reproduction and reduction of the patient's headache, and his clinical experience provides an un-published, yet logical and consistent method for manual examination of the upper cervical spine. Watson describes a similar process to Edwards and Maitland, using sensitizing movements such as upper cervical flexion, ipsilateral and contralateral rotation, and cephalad/caudad/transverse inclinations on the specified level to assist localization of a symptomatic level and with headache reproduction.

Below is how I think about structural differentiation of palpation of the upper cervical spine:

Posterior-anterior (PA) pressure on left C1 with the head in right rotation and flexion increases stretch at C1/2 joint.

PA pressure on left C2 in right rotation and flexion decreases stretch at C1/2 joint.

PA pressure on left C2 with head in left rotation and extension increases stretch at C1/2 joint.

PA pressure on left C1 with head in left rotation and extension decreases rotation at C1/2 joint.

A few additional points to add to the structural differentiation above are (Edwards, 1992):

In extension and contralateral rotation: AP on the C1 increases stress at the O-C1 joint but decreases stress on the C1-2 joint AP on the C2 increases stress at the C1-2 joint PA on the C1 decreases stress at O-C1 joint

In flexion and ipsilateral rotation AP on C1 decreases stress at O-C1 joint PA on C1 decreases stress at C1-2 joint PA on C2 increases stress at C1-2 joint

In flexion and contralateral rotation AP on C2 increases stress at C1-2 joint AP on C1 decreases stress at C1-2 joint PA on C1 increases stress at C1-2 joint



Once you have identified the joint which you wish to treat i.e. O-C1, C1-C2, C2-C3 and decided if the joint has an issue with opening or closing based on your palpation findings, you can select a treatment that you are both comfortable with, proficient at performing, and will address these treatment findings. This might include a joint mobilisation (PAIVM or PPIVM), joint high velocity thrust, muscle energy techniques (MET), active release therapy (ART) or soft tissue massage (STM)….. there are many options to choose from.





Sian Smale is an Australian-trained Musculoskeletal Physiotherapist. Sian completed her Bachelor of Physiotherapy through La Trobe University in 2009 and in 2013 was awarded a Masters in Musculoskeletal Physiotherapy through Melbourne University. Since graduating from her Masters program, Sian has been working in a Private Practice setting and writing a Physiotherapy Blog "Rayner & Smale". Prior to moving to San Francisco, Sian worked at Physical Spinal and Physiotherapy Clinic and has a strong background in manual therapy and management of spinal spine, headaches and sports injuries. Since moving to the Bay area, Sian has become a Physiotherapist for the Olympic Winter Institute of Australia, traveling with their Para Alpine teams.

www.siansmale.com www.raynersmale.com https://www.facebook.com/Rayner-Smale-707802709299693/ twitter @siansmale

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BLOGS PREVIOUSLY WRITTEN ON THE CERVICAL SPINE

Cervical Radiculopathy

Cervical Motor Control

Manual Therapy

Pain-related

Cervicogenic dizziness

References

Edwards, B. C. (1992). Manual of combined movements: their use in the examination and treatment of mechanical vertebral column disorders: Churchill Livingstone.

Jull, G., Amiri, M., Bullock-Saxton, J., Darnell, R., & Lander, C. (2007). Cervical musculoskeletal impairment in frequent intermittent headache. Part 1: Subjects with single headaches. Cephalalgia, 27(7), 793-802.

Jull, G., Sterling, M., Falla, F., Treleaven, J., & O'Leary, S. (2009). Whiplash, headache and neck pain. Edinburgh: Elsevier Churchill-Livingstone.

King, W., Lau, P., Lees, R., & Bogduk, N. (2007). The validity of manual examination in assessing patients with neck pain. The Spine Journal, 7(1), 22-26.

Maitland, G. D., & Hengeveld, E. (2005). Maitland's vertebral manipulation. Edinburg: Elsevier Butterworth-Heinemann.

Watson, D. (2008). The role of Co-C3 Segmental Dysfunction in Primary Headache.Unpublished manuscript, Murdoch university, WA.

Zito, G., Jull, G., & Story, I. (2006). Clinical tests of musculoskeletal dysfunction in the diagnosis of cervicogenic headache. Manual therapy, 11(2), 118-129.