Assessing the Synovial Joint Of The Cervical Spine
Written by David A. Zulak, MA, RMT
I would like to give a few treatment suggestions based on the testing from the previous article. The tests presented in that article were:
1. Test for the OA joint restrictions in flexion and extension that differentiates between which side is restricted.
2. Test for the AA joint restrictions with respect to whether the joint is restricted in rotation to the right or left.
3. Test for C2-C7 facet joint restrictions with respect to whether the joint is restricted because either the left or right joint would not open (flex) or close (extend). This examined the joint’s ability to ‘translate’ (slide side to side) which requires the joint to side bend. As side-bending and rotation are coupled to
the same side in this area of the spine finding a test positive for a problem with side-bending means that rotation will be problematic, (side-bending and rotation), as well as having a restriction with either flexion or extension.
The advantages of these tests are that they can also be performed during the massage. Especially in that scenario where the patient says, as you are midway through the massage: “Oh, by the way, my neck has been bothering me …” Or, when palpation of the tissues during the massage reveals restrictions and/or tenderness. Once the test is performed the patient can be treated right away as need be and usually in the same position.
A. If the therapist finds a positive test for OA joint (occipital-Atlas; O-C1) restriction, as described in the preceding article, there is a great general classic Muscle Energy technique1 to release the sub-occipital muscles. These muscles can either be the source of OA joint restrictions, or, at least, are inevitably involved in such restrictions. It is best to precede treatment with a “sub-occipital release,”2 which allows the therapist to gauge the tension in the muscles in the sub-occipital area. This technique itself can be used as a general (non-specific) test for possible problems with the OA joint and accompanying muscles.
• The therapist positions the supine client’s head into neutral and presses into the sub-occipital region with
the finger pads, while the occiput of the head is supported by the palms (or hypo and hyper thenar eminences) of the hand. The therapist is waiting for the tissues between the base of the skull and C1 to soften or ‘melt’ and allow the fingers to sink into the tissues of the large extensors of the head. This allows the therapist to palpate even deeper tissues, the tone of the “sub-occipital muscles.” If these later are tense then the therapist can wait further till these soften.
• If this deep release does occur then the therapist may feel the occiput slide towards the table, into their palms. (Or, feel a fuller weight to the head in their palms.) The spine may remain where it is or ‘lift’ gently ahead of the palpating fingers.
Now, if no release is felt, or only a minor release, where the sub-occipital muscles remain tense or tender then the following M.E. technique can be used. Note: if it is usual for the therapist to do a ‘sub-occipital release’ during a cervical massage and the sub-occipital muscles and tissue do not ‘melt’ as the therapist would hope for then the therapist can do the following as well.
Lightly traction the cervical spine while the patient is supine. Lift the head slightly off the table and tell the client to tuck the chin in. They should only go to the point of comfort, otherwise they should back off till pain or discomfort disappears. There need be only a little flexion in the lower quadrant of the cervical spine as our treatment focus is in the upper quadrants. A comfortable feeling of stretch is okay. Support this position with one hand cupping the occiput and the other just above the forehead (i.e., just behind the normal hairline). Tell the client to relax.
• The therapist positions the supine client’s head into neutral and presses into the sub-occipital region with
the finger pads, while the occiput of the head is supported by the palms (or hypo & hyper thenar eminences) of the hand. The therapist is waiting for the tissues between the base of the skull and C1 to soften or ‘melt’ and allow the fingers to sink into the tissues of the large extensors of the head. This allows the therapist to palpate even deeper tissues, the tone of the “sub-occipital muscles.” If these later are tense then the therapist can wait further till these soften.
The therapist should run through the following steps with the patient prior to doing the treatment so that the patient understands what is to happen and what to expect. Explain to the client that the sub-occipital and fine small muscles around the cervical spine respond to movements of the eyes – that there is a neurological link. As the head will usually follow the movements of the eyes (unless one consciously resists doing so) these highly proprioceptive loaded muscles contract; to protect the spine by co-ordinating the movements of (or stabilization of) the numerous joints involved. Once this protective reflexive control and stabilization has occurred then the larger muscles of the neck engage and do the ‘gross movements.’3
• Have the client take in a deep breath and hold it as the therapist then has them…
• Roll their eyes up and “try to look up under your eyebrows.” (If the therapist does not feel any pressure of the head trying to extend against their resistance, then tell the patient to lift their chin towards the ceiling with very little force – minimal strength – as we are not seeking to engage the large extensors of the neck, if at all possible.)
• Count out loud “5…4…3…2…1...”
• Then tell the patient to “now look down with the eyes and breathe out. Relax completely … let the breath
out like a relaxing sign.”
• The therapist, in the mean time, keeps their resistive force and gently moves the upper spine – the upper quadrant – into more flexion. Try to focus on not having the whole cervical spine flex, but on the occiput sliding back/down on C1, which is seen by the chin tucking in a little further than where you started.
• Repeat two or three more times till it feels that the OA joint has flexed as far as it can.
Now, when the therapist again does a sub-occipital release they should feel that the tissue is softer and that it will quickly ‘melt’ letting the pads of the fingers sink in.
B. To treat dysfunctions of the Atlanto-Axial jt, (AA joint, C1-C21 joint) which are restrictions in rotation, the therapist can do the following Muscle Energy technique:
• Position the patient as in testing the AA joint. (See previous article.) With one hand have C1 or C2 in the web space between the thumb and index fingers, and you can have the occiput resting in the palm of that hand. Take the free hand and place it on the ‘crown of the head’ (occiput-parietals area). All this time the patient’s cervical spine is held in flexion to help prevent movement in the lower quadrants of the cervical spine.
• Rotate the head till the restriction is felt, or as far as is pain free for the patient. Let us say that rotation is limited towards the left, and so the head is rotated as far to the left as is comfortable for the patient. The therapist places their right hand against the right side of the patients face, with the focus of resisting movement to the right at and above the cheek bone, so as not to press against the jaw (Temporal Mandibular Joint).
• Instruct the client to take in a deep breathe and hold, and then look to the right; which will engage any small spinal muscles that could be short and restricting movement to the left.
• Count down “5…4…3…2…1…now breath out, look to the left, and relax completely…”
• The therapist immediately then gently moves, (or, allows the head move or fall) to the left as far as it comfortably will do so.
• Repeat two or three more times until rotation left is free and full.
This technique works well with restrictions that are muscular, including situations where C1 is rotated on C2.4
If the restriction is within the joint the splinting tense musculature is relaxed and the gentle persuasion of this technique can often mobilize the joint itself. If not much rotation is gained or equalized then massage the cervical spine for a little longer (working the larger gross muscles), and try the techniques mentioned above for the OA joint. This will relax shortened extensors that may be compressing C1-C2 together5, and then try this AA joint technique again.
Done in combination these techniques are a great way to treat a sub-occipital headache; are one of the most successful and least irritating ways to diminish or end such a headache in a patient who arrives with one. A very gentle mix of patient passive range of motion, contract-relax stretching with the mildest of contractions and joint mobilization.
C. Turning to our testing of C2-C7 lower quadrant facet joints we can apply the very testing itself, through repetition, as a possible treatment modality itself. With gentle and pain-free translating through the level that has restriction the muscles and joint can release, especially if the lesion is mild and very recent.
To treat those restrictions that are resistant to the above passive repetition of joint movement (translation) or with those restrictions that are more severe or chronic the following technique works very well. It can be done during the classic Swedish massage treatment, or can be done alone supine or seated.
Example: The cervical spine is held in flexion, so the facet joints are placed in a position that should hold them open. If a restriction is found translating from the left to the right when the cervical spine is being held in flexion, say at C5-C6, then what has been found is that the right facet is not, or will not, open as it should if the spine is to side bend towards the left in order to complete the translation movement to the right. If the facet is not open, or will not open, then it is also being held rotated to the right and will resist rotating left.
In this example: We are testing to see if the joints will all flex (or open); or, are any joints being held in extension (closed). We are testing flexion to see if there are ‘facets stuck closed’ (are locked in extension).
• Saying that the facet will not open equals saying it will not flex.
– It is being held closed or extended.
• Saying that the facet will not open equals saying it will not side bend
to the left.
– It is being held side bent right.
• Saying that the facet will not open equals saying it will not rotate left.
– It is being held rotated right.
Thus, with this testing via translating the lower cervical spine or quadrants we are in fact testing the facet joints in three planes of action: flexion-extension (movement through the median or sagittal plane), rotation left-right (transverse plane) and side-bending (through the coronal plane).
To treat a lower quadrant facet we have to ‘locate’ the lesion site in all three planes: That means moving the joint in all three planes, one at a time, till resistance to further movement is felt, which is at the lesion site itself.
1. We have to slowly flex the vertebrae one at a time till we feel that movement’s force reaching that level.
2. We will have to side bend all the vertebrae one at a time till we feel the movement’s force reach that level,
(or, feel the resistance to side-bending begin at that specific level).
3. We will then rotate the spine till we find the point of resistance.
The easiest way to do the above is to redo the translation test and then ‘place-mark’ it with the thumb and index finger of one hand, either resting under the articular surfaces (“articular pillars”), or lightly palpating the transverse processes of the superior vertebrae (TVP). Take the head, supported in the palm of the other hand, and bring it back to neutral.
1. Now, with the one hand still
holding at the site of restriction take the head and lower it as much as possible.
2. Begin to slowly flex the vertebrae above – one at a time – from C1 down till you feel the force of flexion at the site of restriction.
3. Gently side bend the spine by ‘rotating’ the back of the head parallel to the table, and starting from Occiput-C1 and working down, side bend left, so that each vertebra opens – one at a time – on the right. The therapist is opening the joints like an accordion.
Do so till the side-bending reaches the site of the restriction.
4. Now, rotate (or, let the patient’s face ‘fall’) to the left till the rotation reaches the site of restriction. Now all three planes of movement are focused at the site of restriction.
5. Place your hand at the side of the patient’s skull (above the cheek bone). Ask the patient to take a deep breathe and hold; Look to the right side and up and ‘keep trying to look back around your head.’ The therapist counts out loud: “5…4…3…2…1… now look to the left and down, breathe out like a sigh, and relax.”
6. The therapist ‘follows’ the patient’s eyes, so to speak, by ‘increasing the weight of their hand’ and let the head roll a little more to the left. This means the vertebrae, and hopefully the affected/restricted ones rotate and side bend (which are linked actions). The therapist can also have tried to move slightly into flexion as the patient breathes out – however, this can be cumbersome if they find the weight of the head too much, or cannot be sure by palpation that they are or are not do not flexing ‘through the lesion site and flexing
only vertebrae below.
7. Repeat two or three times.
8. Re-test with translation.
The same procedure, with the appropriate changes, is done for extension restrictions when they are found translating laterally in extension.
This technique may appear complicated, but really is not. Especially if the therapist views it as palpation: movement palpation of the facet joints of the spine, looking for where movement ceases or is restricted, in all three planes, one at a time. Often, this is called “stacking.”
Once placing the patient’s spine in the position where all three planes meet, or are ‘stacked’, the therapist does a contract relax movement to two of those three planes. The patient is asked to move back out away from the restrictions (in at least two of the three planes of movement) by engaging the eyes, so as to contract the very muscles that are short and taut – the very muscles involved in holding the restriction in place. In releasing the tension on the joint the hope is that the joint is now capable of moving and returning to normal mobility post treatment.
The best testing of impairments is one that leads to a clear plan of treatment. Such testing to the synovial joints of the cervical spine leads to the specific treatment for the restrictions found. What is so attractive about the testing presented here is that they can be done prior to, or during the application of therapeutic massage, whenever the impairment is found. Then, the treatment often mirrors the testing, making it easy to remember and be performed.
Part 1 of this article confused side-bending and translation after the last diagram.