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Case report. Clinical instability of the upper cervical spine
Manual Therapy (2000) 5(1), 41±46 # 2000 Harcourt Publishers Ltd DOI: 10.1054/math.1999.0219, available online at http://www.idealibrary.com on
Case report
Clinical instability of the upper cervical spine J. Lincoln Belmere, Temera Road, Young, NSW 2594, Australia
INTRODUCTION
experienced in the morning and the pain was worse when relaxing at the end of a busy day. Aggravating activities included reaching or lifting with the right arm, ironing or wringing out clothes. Cold weather or having in¯uenza generally made all symptoms worse, and blowing her nose or sneezing speci®cally increased her facial pain. Short-term relief from her symptoms was gained with rest or when rubbing a non-prescription gel into the shoulder area.
A female patient presented with symptoms of unilateral right sided head, face, ear, neck, shoulder and arm pain, as well as subjective sensation of swelling in the right side of the face and anterior triangle of the neck. Whilst testing for upper cervical spine stability using the Sharp Purser test it was found that the majority of the patient's symptoms immediately disappeared. The patient was treated with an upper cervical spine Headache Sustained Natural Apophyseal Glide (SNAG) technique (Mulligan 1995) and upper limb neural mobilizations. This, in combination with a home programme of chin retractions and an auto neural mobilization, completely relieved the patient of all symptoms. A discussion on the causes of the pain, clinical instabilities of the cervical spine and clinical reasoning is presented in this paper.
HISTORY The patient presented with an insidious onset of pain over a 12 month period, which had gradually worsened. There was no past history of shoulder or cervical spine pain or injury. She was an active lady who lived by herself and worked voluntarily as a shop assistant. Medical history included insulin dependant diabetes, angina, dizziness associated with postural changes and blurred vision bilaterally for which she had recently been referred to an eye specialist. The patient reported being under an Ear Nose and Throat (ENT) specialist for the previous 2 years for persistent problems, which were not speci®cally detailed. There had been no X-ray or scan performed on the cervical spine.
PRESENTATION A 62-year-old female patient was referred for physiotherapy by her general practitioner for neck pain. The patient complained of a constant ache in the right shoulder and neck extending down the entire anterior aspect of the right arm. This was associated with intermittent pain in the right side of the face, ear and head as well as a constant sensation of swelling in the right side of the face and anterior triangle of the neck. She reported waking at night with right arm pain and with intermittent pins and needles in the right ®ngertips (Fig. 1). She was unable to lie on her right side at night and found left side and prone lying to be the most comfortable sleeping positions. Shortterm stiness of the neck and right shoulder was
OBJECTIVE EXAMINATION The patient was observed in her normal seated posture in a chair. Observation from a lateral view revealed a protracted cervical spine with forward head posture. Active cervical spine movements were visually assessed. There was an increase in the shoulder and neck pain at the end of range for left rotation and left lateral ¯exion. Cervical spine extension produced central thoracic spine pain. Flexion, right rotation and right lateral ¯exion were asymptomatic.
Jessica Lincoln, BApp Sc (Physio), MAPA, Lisa Tynan Physiotherapy and Sports Medicine Centre, Unit D, 10 Bradford Close, Kotara, NSW 2289, Australia. 41
42 Manual Therapy
TREATMENT AND RESULTS Initial visit On the day of initial examination the patient was given a modi®ed auto upper limb neural mobilization exercise for home. Instructions were to stand with her right side beside a table that was at the same height as her hip, and to place her right hand ¯at on the table with ®ngers pointing behind her and her elbow straight. She was then told to turn her body and head away from her right arm, only to the point that reproduced her symptoms, and to hold this for 45 seconds (Fig. 2). The patient was instructed to do this once on a daily basis whilst carefully monitoring her signs and symptoms before and after the technique.
Second visit
Fig. 1ÐBody chart of symptoms.
Active shoulder movements were visually assessed with the patient standing. The patient's arm, shoulder and neck pain was increased with ¯exion from 908 through end range, abduction initially at 1008 through end range, and at the end of range with the hand behind the back movement. External rotation in neutral was full and asymptomatic. Cervical spine palpation was initially performed with the patient sitting in her normal seated posture. This was due to the high irritability of the condition and therefore the position of comfort was chosen. Light palpation revealed tenderness over the right scalenes and upper trapezius muscles, and along the spine of the scapula. Position assessment of the axis vertebra via palpation revealed the right transverse process to be prominent posteriorly as well as tender. This possibly suggested some right rotation of this vertebra. A median nerve bias Upper Limb Tension Test (ULTTI) as described by Butler (1991) was restricted and positive on the right. Initial increase in arm symptoms occurred with the shoulder depression component, with a further increase occurring with any attempt at abduction of the shoulder. The same ULTTI performed on the left side was asymptomatic for the patient's pain and had an end range of 08 elbow extension. Vertebro-basilar insuciency testing (APA Protocol 1988) was negative. Given the patient's high level of irritability, the initial objective examination was limited. Manual Therapy (2000) 5(1), 41±46
The patient reported an initial increase in symptoms for 2 days and then a large decrease in symptoms in the subsequent 4 days. During that time the patient had increased the number of repetitions of the home exercise to ®ve times daily. Examination of active cervical spine movements reproduced right shoulder and neck pain at end of range right rotation and right lateral ¯exion. This was in contrast to the initial examination ®ndings. Active shoulder movements had improved with the reproduction of pain only at the end of range ¯exion and abduction. Given the distribution of the patient's pain, it was decided to test for upper cervical spine stability using the Sharp Purser test (Sharp & Purser 1961) (Fig. 3). At rest in sitting, the patient complained of right sided face, ear, neck and shoulder pain. The therapist stood on the side of the patient's symptoms and glided the head posteriorly whilst stabilizing C2. A large amount of movement was appreciated before
Fig. 2ÐDemonstration of modi®ed upper limb neural mobilization. # 2000 Harcourt Publishers Ltd
Clinical instability of the upper cervical spine 43
The patient's home exercise was progressed to a full ULTTI mobilization; instructions were to perform the same exercise as previously shown, only this time in standing with her right side to a wall and hand placed at shoulder height. Third visit
Fig. 3ÐSharp-Purser test for integrity of the transverse ligament.
The patient reported being ill with the ¯u for several days since last treatment, which had aggravated her symptoms. Despite this, she felt an overall improvement, particularly in the arm pain. Examination of active movements reproduced pain only with end range right cervical rotation and end range shoulder ¯exion. The ULTTI was positive on the right side with the onset of arm pain at end of range elbow extension with other components full. Treatment consisted of therapist assisted ULTTI mobilizations performed twice whereby the therapist sustained wrist extension at the end of range test position for 45 seconds. The therapist then repeated the Headache SNAG (Mulligan 1995) as per last treatment, with ®ve repetitions. On reassessment there was pain free, full range of movement with both right cervical spine rotation and shoulder ¯exion. The patient left physiotherapy completely asymptomatic with instructions to continue with the same home exercise (full ULTTI) as previously given. Fourth visit
the onset of resistance during this test, although no clunk was heard or felt. Afterwards, the patient reported that her symptoms at rest had virtually disappeared to a minor sensation of pain in the right shoulder and neck area. The therapist decided to use a Headache SNAG (Mulligan 1995) for treatment, as this technique resembled the gliding movement performed during testing. Whilst treating the patient using this technique, it was noted that the right sided facial pain increased if the therapist stood on the patient's asymptomatic side. This could be due to an inadvertent change in direction of force applied to C2, resulting in an increase in rotation of C2 to the right. Subsequently, the patient was treated with the therapist standing on the symptomatic side, which consistently decreased the patient's symptoms. Five repetitions of this technique were applied, holding each for 10 seconds with a 10 second rest. Directly after treatment the patient reported being completely asymptomatic. Reassessment revealed a positive ULTTI on the right, with the onset of pain toward the end range of elbow extension with other components of shoulder depression, 908 abduction, wrist extension and supination and shoulder external rotation full. # 2000 Harcourt Publishers Ltd
The patient reported being pain free for 4 days posttreatment until her right sided face, ear and neck pain had been aggravated by ironing. Examination revealed right sided neck pain at rest, which increased toward end of range cervical spine right rotation and left lateral ¯exion. Shoulder movements were asymptomatic. Treatment consisted of two repetitions of the Headache SNAG (Mulligan 1995), resulting in the patient reporting no pain at rest. Cervical spine movements were re-tested and produced minimal pain at end of range. The patient was taught an active chin retraction in supine, with the use of one pillow to support the head, holding each retraction for 5 seconds, and repeating two sets of ®ve repetitions. Following this exercise, active cervical spine movements were completely asymptomatic. The patient was instructed to continue with the neural mobilization at home and to begin chin retractions as practised in treatment. Fifth visit The patient reported a vast improvement in all symptoms, however, she did not feel fully recovered. She was performing the neural mobilization exercise Manual Therapy (2000) 5(1), 41±46
44 Manual Therapy
three times daily as she felt this had helped her arm pain, which had now disappeared. She was carrying out ®ve repetitions of the chin retractions once every other day, mainly after her pain had increased from ironing or lifting. At the time of assessment, the patient reported having her right ear, face and anterior neck pain at rest, which was increased toward end of range cervical spine right rotation. The patient was asked to perform the chin retractions as done at home ± one ¯at pillow was used to support the head and she then performed a gentle chin retraction, holding for 5 seconds. After completing two sets of ®ve repetitions, the patient reported being asymptomatic at rest, and cervical spine right rotation was pain free with full movement. The patient was discharged with the same exercise as previously given, to control her pain.
DISCUSSION Clinical instability In a review of the pathogenesis of upper cervical spine stability, Swinkels et al. (1996) reported that the pharynx has lymphatic connections with the atlantoaxial region. Infections in the tonsils, middle ear, teeth and nose may drain into the cervical spine region and the subsequent in¯ammation may lead to loosening of the transverse ligament attachments (Locke et al. 1996). Cranio-vertebral hypermobility (Grisel's Syndrome) has previously been described in children and adolescents post upper respiratory tract infection (Grieve 1988). In this case report, the patient had been under the care of an ENT specialist for 2 years for persistent
problems in the nasal area, as reported by the patient. This suggests recurrent infections in the pharyngeal area, which may have led to chronic draining of in¯ammation into the upper cervical spine region via lymphatic connections. Objective examination revealed a larger than normal amount of movement with less resistance appreciated by the therapist during the Sharp Purser test. It is therefore possible that this patient's increased mobility was due to chronic loosening of the transverse ligament over time. The patient also reported that a short-term aggravation of symptoms occurred during the in¯uenza virus. This would not be uncommon given the systemic eects of the virus. The stability of the upper cervical spine relies on passive (ligamentous), active (musculotendinous) and neural control subsystems (Panjabi 1992). Panjabi (1992) de®ned clinical instability as a `. . .signi®cant decrease in the capacity of the spine to maintain the intervertebral neutral zones within physiological limits so that there is no neurological dysfunction, no major deformity and no incapacitating pain'. This patient presented with pain at rest, suggesting the spine's inability to maintain a sucient neutral zone to prevent abnormal stresses on upper cervical spine pain producing structures. Therefore the development of a clinical instability situation in this particular patient may have come about through the mechanism illustrated in Figure 4.
Facial pain The distribution of this patient's pain corresponds to areas supplied by the trigeminal nerve and nerves arising from the upper cervical spine (Fig. 5).
Fig. 4ÐProposed mechanism for the development of clinical instability. Manual Therapy (2000) 5(1), 41±46
# 2000 Harcourt Publishers Ltd
Clinical instability of the upper cervical spine 45
plane to the right during assessment using the Headache SNAG (Mulligan 1995). This con®rmed the initial position assessment of this vertebra with a tender and prominent right transverse process. This rotation of C2 would have a similar eect of mechanically deforming the C2 spinal nerve as it crosses the lateral atlantoaxial joint. Management
Fig. 5ÐSensory innervation of the face, head and neck (reprinted with permission from Gray's Anatomy).
Pain felt in the head, throat and neck is due to nociceptive information from the trigeminocervical nucleus. This nucleus receives aerents from the trigeminal nerve and from C1±3 spinal nerves, with additional aerents from the VII, IX and X cranial nerves. Due to the convergence of primary aerent ®bres onto common second-order neurones in the trigeminocervical nucleus, it is possible to experience referred pain in the head and upper neck. Therefore, mechanical or chemical stimulation of cervical spine aerents to a second-order neurone that also receives a trigeminal input may result in the pain being felt in the cervical spine receptive ®eld, and/or the trigeminal receptive ®eld (Bogduk 1995). Given that cervical spine active movements aggravated this patient's facial pain, it is probable that the pain was attributable to a mechanical stimulation in the C1±3 area. Possible causes include mechanical deformation of the transverse ligament, as this is innervated by the sinuvertebral nerves arising from the ventral rami of the C1±3 spinal nerve roots. Upper cervical spine protrusion at rest may also have been mechanically deforming C1 and C2 spinal nerves themselves. The ®rst cervical spinal nerve passes across the posterior arch of the atlas behind its superior articular process, while the C2 spinal nerve crosses the posterior aspect of the lateral atlantoaxial joint (Bogduk 1995). A right rotation of the C2 vertebra was indicated by an increase in symptoms when angulating the force applied in the sagittal # 2000 Harcourt Publishers Ltd
There is little researched evidence as to why or how a Headache SNAG may be eective (Mulligan 1995). One explanation is that it realigns the atlas on the axis and therefore decreases stress on all surrounding pain-producing structures. In this case report, the patient presented with a right rotated C2 vertebra. Instead of applying a direct sagittal force on the spinous process of C2, the therapist angulated the force across the sagittal plane to the left, which may have resulted in a left rotation of the vertebra. Therefore, decreased input into the trigeminocervical nucleus would result from correction of the vertebral right rotation in conjunction with upper cervical spine protrusion. This case report highlights the need to investigate thoroughly the exact position of the vertebra when performing any technique where the aim is to reinstate normal vertebral alignment. Using a reasoned approach, modi®cations of existing techniques should be experimented with in order to achieve the desired goal. Once vertebral alignment has been achieved it is necessary to train the neuromuscular subsystem to maintain this position. An upper cervical spine ¯exion movement recruits super®cial and deep neck ¯exor muscles. The deep neck ¯exor muscles, particularly longus colli, play a postural, supporting role enabling segmental stability (Conley et al. 1995; Jull 1997). It is possible that in this particular case, the gentle chin retraction exercise was bene®cial for two reasons. Firstly, by retracting the head in supine, the atlas vertebra would also retract into alignment with the axis. Secondly, the movement performed may have been recruiting deep neck ¯exor muscles, resulting in improved segmental muscular control of the upper cervical region. This muscular activation also improves proprioception of the head and neck (Jull 1997). Pain presenting in lines in a non dermatomal distribution could be suggestive of compromised neural tissue (Butler 1991). In this case report, a modi®ed upper limb neural mobilization signi®cantly decreased the patient's arm pain. The exact mechanisms behind the treatment of compromised neural tissue are not yet fully understood. It is believed that mobilizing the nervous system has a mechanical eect on vascular dynamics, axonal transport and on the mechanical features of the nerve ®bres and connective tissues (Butler 1991). It is possible that this patient's Manual Therapy (2000) 5(1), 41±46
46 Manual Therapy
upper cervical spine posture was causing deformation of the interfacing structures with peripheral nerves in the area. This could lead to irritation of the nervi nervorum in the peripheral nerve connective tissue sheath, which is capable of producing referred pain, constant and aching in nature (Butler 1991). This deformation would also result in ischaemia in the area over time. Given this patient's initial rapid improvement in the symptoms following mobilization of the nervous systems, it is probable that this was due to improved blood supply to hypoxic nerve ®bres. Through mobilizing the nervous system and treating interfacing tissues, a normalization of pressure gradients within the nerve would result, ultimately leading to improved blood supply (Butler 1991). CONCLUSION In this case report, a female patient presented with the unusual symptoms of unilateral pain in the head, face, ear, neck, shoulder and arm extending to the hand. Objective ®ndings revealed hypermobility in the upper cervical spine and it is reasoned that this led to mechanical stimulation of the trigeminocervical nucleus. The patient was treated with manual therapy techniques resulting in prompt relief of symptoms.
Manual Therapy (2000) 5(1), 41±46
This is a single case report showing evidence of successful management of a clinical instability of the cervical spine and the possible reasoning behind this.
References Australian Physiotherapy Association 1988 Protocol for premanipulative testing of the cervical spine. Australian Journal of Physiotherapy 34: 97±100 Bogduk N 1995 Anatomy and physiology of headache. Biomedicine and Pharmacotherapy 49(10): 435±445 Butler D 1991 Mobilization of the Nervous System. Churchill Livingstone, Melbourne, pp 77±78, 148, 196 Conley MS, Meyer RA, Bloomberg JJ, Feeback DL, Dudley GA 1995 Non-invasive analysis of human neck muscle function. Spine 20: 2205±2512 Grieve G 1988 Common Vertebral Joint Problems, 2nd Edn. Churchill Livingstone, Edinburgh p361 Jull G 1997 Management of cervical headache. Manual Therapy 2(4): 182±190 Locke G, Gardner J, Van Epps F 1996 Atlas-dens Interval (ADI) in children. American Journal of Roentgenology 97: 135±140 Mulligan B 1995 Manual Therapy ``NAGS'', ``SNAGS'', ``MWMs'', etc. 3rd Edn. Plane View Services, Wellington, pp36±37 Panjabi M 1992 The stabilising system of the spine. Part I and Part II. Journal of Spinal Disorders 5(4): 383±397 Sharp J, Purser D 1961 Spontaneous atlanto-axial dislocation in ankylosing spondylitis and rheumatoid arthritis. Annals of Rheumatology Disorders 20: 47±74 Swinkels R, Beeton K, Alltree J 1996 Pathogenesis of upper cervical instability. Manual Therapy 1: 127±132
# 2000 Harcourt Publishers Ltd
Case report
Clinical instability of the upper cervical spine J. Lincoln Belmere, Temera Road, Young, NSW 2594, Australia
INTRODUCTION
experienced in the morning and the pain was worse when relaxing at the end of a busy day. Aggravating activities included reaching or lifting with the right arm, ironing or wringing out clothes. Cold weather or having in¯uenza generally made all symptoms worse, and blowing her nose or sneezing speci®cally increased her facial pain. Short-term relief from her symptoms was gained with rest or when rubbing a non-prescription gel into the shoulder area.
A female patient presented with symptoms of unilateral right sided head, face, ear, neck, shoulder and arm pain, as well as subjective sensation of swelling in the right side of the face and anterior triangle of the neck. Whilst testing for upper cervical spine stability using the Sharp Purser test it was found that the majority of the patient's symptoms immediately disappeared. The patient was treated with an upper cervical spine Headache Sustained Natural Apophyseal Glide (SNAG) technique (Mulligan 1995) and upper limb neural mobilizations. This, in combination with a home programme of chin retractions and an auto neural mobilization, completely relieved the patient of all symptoms. A discussion on the causes of the pain, clinical instabilities of the cervical spine and clinical reasoning is presented in this paper.
HISTORY The patient presented with an insidious onset of pain over a 12 month period, which had gradually worsened. There was no past history of shoulder or cervical spine pain or injury. She was an active lady who lived by herself and worked voluntarily as a shop assistant. Medical history included insulin dependant diabetes, angina, dizziness associated with postural changes and blurred vision bilaterally for which she had recently been referred to an eye specialist. The patient reported being under an Ear Nose and Throat (ENT) specialist for the previous 2 years for persistent problems, which were not speci®cally detailed. There had been no X-ray or scan performed on the cervical spine.
PRESENTATION A 62-year-old female patient was referred for physiotherapy by her general practitioner for neck pain. The patient complained of a constant ache in the right shoulder and neck extending down the entire anterior aspect of the right arm. This was associated with intermittent pain in the right side of the face, ear and head as well as a constant sensation of swelling in the right side of the face and anterior triangle of the neck. She reported waking at night with right arm pain and with intermittent pins and needles in the right ®ngertips (Fig. 1). She was unable to lie on her right side at night and found left side and prone lying to be the most comfortable sleeping positions. Shortterm stiness of the neck and right shoulder was
OBJECTIVE EXAMINATION The patient was observed in her normal seated posture in a chair. Observation from a lateral view revealed a protracted cervical spine with forward head posture. Active cervical spine movements were visually assessed. There was an increase in the shoulder and neck pain at the end of range for left rotation and left lateral ¯exion. Cervical spine extension produced central thoracic spine pain. Flexion, right rotation and right lateral ¯exion were asymptomatic.
Jessica Lincoln, BApp Sc (Physio), MAPA, Lisa Tynan Physiotherapy and Sports Medicine Centre, Unit D, 10 Bradford Close, Kotara, NSW 2289, Australia. 41
42 Manual Therapy
TREATMENT AND RESULTS Initial visit On the day of initial examination the patient was given a modi®ed auto upper limb neural mobilization exercise for home. Instructions were to stand with her right side beside a table that was at the same height as her hip, and to place her right hand ¯at on the table with ®ngers pointing behind her and her elbow straight. She was then told to turn her body and head away from her right arm, only to the point that reproduced her symptoms, and to hold this for 45 seconds (Fig. 2). The patient was instructed to do this once on a daily basis whilst carefully monitoring her signs and symptoms before and after the technique.
Second visit
Fig. 1ÐBody chart of symptoms.
Active shoulder movements were visually assessed with the patient standing. The patient's arm, shoulder and neck pain was increased with ¯exion from 908 through end range, abduction initially at 1008 through end range, and at the end of range with the hand behind the back movement. External rotation in neutral was full and asymptomatic. Cervical spine palpation was initially performed with the patient sitting in her normal seated posture. This was due to the high irritability of the condition and therefore the position of comfort was chosen. Light palpation revealed tenderness over the right scalenes and upper trapezius muscles, and along the spine of the scapula. Position assessment of the axis vertebra via palpation revealed the right transverse process to be prominent posteriorly as well as tender. This possibly suggested some right rotation of this vertebra. A median nerve bias Upper Limb Tension Test (ULTTI) as described by Butler (1991) was restricted and positive on the right. Initial increase in arm symptoms occurred with the shoulder depression component, with a further increase occurring with any attempt at abduction of the shoulder. The same ULTTI performed on the left side was asymptomatic for the patient's pain and had an end range of 08 elbow extension. Vertebro-basilar insuciency testing (APA Protocol 1988) was negative. Given the patient's high level of irritability, the initial objective examination was limited. Manual Therapy (2000) 5(1), 41±46
The patient reported an initial increase in symptoms for 2 days and then a large decrease in symptoms in the subsequent 4 days. During that time the patient had increased the number of repetitions of the home exercise to ®ve times daily. Examination of active cervical spine movements reproduced right shoulder and neck pain at end of range right rotation and right lateral ¯exion. This was in contrast to the initial examination ®ndings. Active shoulder movements had improved with the reproduction of pain only at the end of range ¯exion and abduction. Given the distribution of the patient's pain, it was decided to test for upper cervical spine stability using the Sharp Purser test (Sharp & Purser 1961) (Fig. 3). At rest in sitting, the patient complained of right sided face, ear, neck and shoulder pain. The therapist stood on the side of the patient's symptoms and glided the head posteriorly whilst stabilizing C2. A large amount of movement was appreciated before
Fig. 2ÐDemonstration of modi®ed upper limb neural mobilization. # 2000 Harcourt Publishers Ltd
Clinical instability of the upper cervical spine 43
The patient's home exercise was progressed to a full ULTTI mobilization; instructions were to perform the same exercise as previously shown, only this time in standing with her right side to a wall and hand placed at shoulder height. Third visit
Fig. 3ÐSharp-Purser test for integrity of the transverse ligament.
The patient reported being ill with the ¯u for several days since last treatment, which had aggravated her symptoms. Despite this, she felt an overall improvement, particularly in the arm pain. Examination of active movements reproduced pain only with end range right cervical rotation and end range shoulder ¯exion. The ULTTI was positive on the right side with the onset of arm pain at end of range elbow extension with other components full. Treatment consisted of therapist assisted ULTTI mobilizations performed twice whereby the therapist sustained wrist extension at the end of range test position for 45 seconds. The therapist then repeated the Headache SNAG (Mulligan 1995) as per last treatment, with ®ve repetitions. On reassessment there was pain free, full range of movement with both right cervical spine rotation and shoulder ¯exion. The patient left physiotherapy completely asymptomatic with instructions to continue with the same home exercise (full ULTTI) as previously given. Fourth visit
the onset of resistance during this test, although no clunk was heard or felt. Afterwards, the patient reported that her symptoms at rest had virtually disappeared to a minor sensation of pain in the right shoulder and neck area. The therapist decided to use a Headache SNAG (Mulligan 1995) for treatment, as this technique resembled the gliding movement performed during testing. Whilst treating the patient using this technique, it was noted that the right sided facial pain increased if the therapist stood on the patient's asymptomatic side. This could be due to an inadvertent change in direction of force applied to C2, resulting in an increase in rotation of C2 to the right. Subsequently, the patient was treated with the therapist standing on the symptomatic side, which consistently decreased the patient's symptoms. Five repetitions of this technique were applied, holding each for 10 seconds with a 10 second rest. Directly after treatment the patient reported being completely asymptomatic. Reassessment revealed a positive ULTTI on the right, with the onset of pain toward the end range of elbow extension with other components of shoulder depression, 908 abduction, wrist extension and supination and shoulder external rotation full. # 2000 Harcourt Publishers Ltd
The patient reported being pain free for 4 days posttreatment until her right sided face, ear and neck pain had been aggravated by ironing. Examination revealed right sided neck pain at rest, which increased toward end of range cervical spine right rotation and left lateral ¯exion. Shoulder movements were asymptomatic. Treatment consisted of two repetitions of the Headache SNAG (Mulligan 1995), resulting in the patient reporting no pain at rest. Cervical spine movements were re-tested and produced minimal pain at end of range. The patient was taught an active chin retraction in supine, with the use of one pillow to support the head, holding each retraction for 5 seconds, and repeating two sets of ®ve repetitions. Following this exercise, active cervical spine movements were completely asymptomatic. The patient was instructed to continue with the neural mobilization at home and to begin chin retractions as practised in treatment. Fifth visit The patient reported a vast improvement in all symptoms, however, she did not feel fully recovered. She was performing the neural mobilization exercise Manual Therapy (2000) 5(1), 41±46
44 Manual Therapy
three times daily as she felt this had helped her arm pain, which had now disappeared. She was carrying out ®ve repetitions of the chin retractions once every other day, mainly after her pain had increased from ironing or lifting. At the time of assessment, the patient reported having her right ear, face and anterior neck pain at rest, which was increased toward end of range cervical spine right rotation. The patient was asked to perform the chin retractions as done at home ± one ¯at pillow was used to support the head and she then performed a gentle chin retraction, holding for 5 seconds. After completing two sets of ®ve repetitions, the patient reported being asymptomatic at rest, and cervical spine right rotation was pain free with full movement. The patient was discharged with the same exercise as previously given, to control her pain.
DISCUSSION Clinical instability In a review of the pathogenesis of upper cervical spine stability, Swinkels et al. (1996) reported that the pharynx has lymphatic connections with the atlantoaxial region. Infections in the tonsils, middle ear, teeth and nose may drain into the cervical spine region and the subsequent in¯ammation may lead to loosening of the transverse ligament attachments (Locke et al. 1996). Cranio-vertebral hypermobility (Grisel's Syndrome) has previously been described in children and adolescents post upper respiratory tract infection (Grieve 1988). In this case report, the patient had been under the care of an ENT specialist for 2 years for persistent
problems in the nasal area, as reported by the patient. This suggests recurrent infections in the pharyngeal area, which may have led to chronic draining of in¯ammation into the upper cervical spine region via lymphatic connections. Objective examination revealed a larger than normal amount of movement with less resistance appreciated by the therapist during the Sharp Purser test. It is therefore possible that this patient's increased mobility was due to chronic loosening of the transverse ligament over time. The patient also reported that a short-term aggravation of symptoms occurred during the in¯uenza virus. This would not be uncommon given the systemic eects of the virus. The stability of the upper cervical spine relies on passive (ligamentous), active (musculotendinous) and neural control subsystems (Panjabi 1992). Panjabi (1992) de®ned clinical instability as a `. . .signi®cant decrease in the capacity of the spine to maintain the intervertebral neutral zones within physiological limits so that there is no neurological dysfunction, no major deformity and no incapacitating pain'. This patient presented with pain at rest, suggesting the spine's inability to maintain a sucient neutral zone to prevent abnormal stresses on upper cervical spine pain producing structures. Therefore the development of a clinical instability situation in this particular patient may have come about through the mechanism illustrated in Figure 4.
Facial pain The distribution of this patient's pain corresponds to areas supplied by the trigeminal nerve and nerves arising from the upper cervical spine (Fig. 5).
Fig. 4ÐProposed mechanism for the development of clinical instability. Manual Therapy (2000) 5(1), 41±46
# 2000 Harcourt Publishers Ltd
Clinical instability of the upper cervical spine 45
plane to the right during assessment using the Headache SNAG (Mulligan 1995). This con®rmed the initial position assessment of this vertebra with a tender and prominent right transverse process. This rotation of C2 would have a similar eect of mechanically deforming the C2 spinal nerve as it crosses the lateral atlantoaxial joint. Management
Fig. 5ÐSensory innervation of the face, head and neck (reprinted with permission from Gray's Anatomy).
Pain felt in the head, throat and neck is due to nociceptive information from the trigeminocervical nucleus. This nucleus receives aerents from the trigeminal nerve and from C1±3 spinal nerves, with additional aerents from the VII, IX and X cranial nerves. Due to the convergence of primary aerent ®bres onto common second-order neurones in the trigeminocervical nucleus, it is possible to experience referred pain in the head and upper neck. Therefore, mechanical or chemical stimulation of cervical spine aerents to a second-order neurone that also receives a trigeminal input may result in the pain being felt in the cervical spine receptive ®eld, and/or the trigeminal receptive ®eld (Bogduk 1995). Given that cervical spine active movements aggravated this patient's facial pain, it is probable that the pain was attributable to a mechanical stimulation in the C1±3 area. Possible causes include mechanical deformation of the transverse ligament, as this is innervated by the sinuvertebral nerves arising from the ventral rami of the C1±3 spinal nerve roots. Upper cervical spine protrusion at rest may also have been mechanically deforming C1 and C2 spinal nerves themselves. The ®rst cervical spinal nerve passes across the posterior arch of the atlas behind its superior articular process, while the C2 spinal nerve crosses the posterior aspect of the lateral atlantoaxial joint (Bogduk 1995). A right rotation of the C2 vertebra was indicated by an increase in symptoms when angulating the force applied in the sagittal # 2000 Harcourt Publishers Ltd
There is little researched evidence as to why or how a Headache SNAG may be eective (Mulligan 1995). One explanation is that it realigns the atlas on the axis and therefore decreases stress on all surrounding pain-producing structures. In this case report, the patient presented with a right rotated C2 vertebra. Instead of applying a direct sagittal force on the spinous process of C2, the therapist angulated the force across the sagittal plane to the left, which may have resulted in a left rotation of the vertebra. Therefore, decreased input into the trigeminocervical nucleus would result from correction of the vertebral right rotation in conjunction with upper cervical spine protrusion. This case report highlights the need to investigate thoroughly the exact position of the vertebra when performing any technique where the aim is to reinstate normal vertebral alignment. Using a reasoned approach, modi®cations of existing techniques should be experimented with in order to achieve the desired goal. Once vertebral alignment has been achieved it is necessary to train the neuromuscular subsystem to maintain this position. An upper cervical spine ¯exion movement recruits super®cial and deep neck ¯exor muscles. The deep neck ¯exor muscles, particularly longus colli, play a postural, supporting role enabling segmental stability (Conley et al. 1995; Jull 1997). It is possible that in this particular case, the gentle chin retraction exercise was bene®cial for two reasons. Firstly, by retracting the head in supine, the atlas vertebra would also retract into alignment with the axis. Secondly, the movement performed may have been recruiting deep neck ¯exor muscles, resulting in improved segmental muscular control of the upper cervical region. This muscular activation also improves proprioception of the head and neck (Jull 1997). Pain presenting in lines in a non dermatomal distribution could be suggestive of compromised neural tissue (Butler 1991). In this case report, a modi®ed upper limb neural mobilization signi®cantly decreased the patient's arm pain. The exact mechanisms behind the treatment of compromised neural tissue are not yet fully understood. It is believed that mobilizing the nervous system has a mechanical eect on vascular dynamics, axonal transport and on the mechanical features of the nerve ®bres and connective tissues (Butler 1991). It is possible that this patient's Manual Therapy (2000) 5(1), 41±46
46 Manual Therapy
upper cervical spine posture was causing deformation of the interfacing structures with peripheral nerves in the area. This could lead to irritation of the nervi nervorum in the peripheral nerve connective tissue sheath, which is capable of producing referred pain, constant and aching in nature (Butler 1991). This deformation would also result in ischaemia in the area over time. Given this patient's initial rapid improvement in the symptoms following mobilization of the nervous systems, it is probable that this was due to improved blood supply to hypoxic nerve ®bres. Through mobilizing the nervous system and treating interfacing tissues, a normalization of pressure gradients within the nerve would result, ultimately leading to improved blood supply (Butler 1991). CONCLUSION In this case report, a female patient presented with the unusual symptoms of unilateral pain in the head, face, ear, neck, shoulder and arm extending to the hand. Objective ®ndings revealed hypermobility in the upper cervical spine and it is reasoned that this led to mechanical stimulation of the trigeminocervical nucleus. The patient was treated with manual therapy techniques resulting in prompt relief of symptoms.
Manual Therapy (2000) 5(1), 41±46
This is a single case report showing evidence of successful management of a clinical instability of the cervical spine and the possible reasoning behind this.
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# 2000 Harcourt Publishers Ltd