treating headaches and migraines - david zulak headaches and... · treating headaches and migraines...

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Treating Headaches & Migraines © David Zulak MA, RMT Nov.2-3 @ Kananaskis AB www.davidzulak.com

Treating Headaches and Migraines

Always listen to what the client tells you, and what the tissues tell you; about speed, depth, repetitions, moving on, skipping, coming back to or repeating, and the like. Slow, precise, movements are the key to success. The client needs to become comfortable with your touch – your sensitivity, your responsiveness, and your nurturing nature.

Trigeminocervical nucleus

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Note: Whether you use all or only some of the following suggested techniques will depend on each specific client and their condition at the time of treatment. The positions and techniques used are highly dependent on the client’s comfort and consent.

Remember: Keep your focus not just on the musculature and joint structures. Intention should also clearly be directed to arterial, venous and lymphatic flow; motor and sensory nerves and the autonomics!

Prone – This position is used primarily as an introduction to treatment. It is often not used because of either client comfort, or more usually, because of it can be the least effect position for treating the upper back and neck. [Note, however, some client’s find the pressure around the face while laying prone using a face-cradle comforting, while others find it exacerbates their symptoms.]

Most useful when addressing some of the muscles involved in postural distortions (between headaches):

• Low back musculature when addressing a hyper-lordosis (first “blocking” under ASIS’s); • the mid-back (thoracic) region) – especially the Lower trapezius, latissimus dorsi, rhomboid

major, erector spinae and scapular muscles – when the shoulders have been “blocked”; • For some introductory work in the upper back, shoulder girdle, and neck area. Sidelying is

usually better for detailed work in these areas.

Techniques often used are: Swedish massage; indirect joint mobilization; joint oscillations/rhythmic-mobilizations of the hips, spine, shoulder girdle; myofascial techniques; acupressure points… Almost anything goes depending on the client’s presentation, where in the treatment-plan the client is, etc.

Sidelying – This positioning of the client is usually employed because of its specificity and effectiveness in addressing all the tissues and structures that need to be treated. Most clients presenting with HA/migraine, whom you have treated for some time, will actually prefer you begin here, once you are proficient and your movements are gentle, specific, and intentional.

A good way to be very specific is to think through the anatomical tissues and structures: for example trace out, one at a time, the muscle – its attachment sites (and the border of flat muscles like the upper and middle trapezius); palpate joints and visualize joint capsules and ligaments; lightly trace arteries &veins, lymphatic nodes, cervical sympathetic ganglion… Thinking through such a list helps to remember to address everything, and use the techniques applicable to each type of tissue and its condition.

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• Shoulder Girdle motion; oscillations… • Gentle, incrementally increasing, tractions…

o GH → AC-SC-Scapula → Spinal Segments → Cranial Vault & Dura

• Specific (‘tracing’) treatments of: Shoulder Girdle → Upper Thoracics (T1- T5) & Cervicals → Cranium → Side of Cranium & face/jaw

o Vibrations, Stroking, Effleurage, Petrasauge, Rhythmic-mobs, Drainage, [Myofascial]

o Strain-Counter-Strain; M.E.T./P.I.R. o Neural-inhibitory techniques; Decompressions for

Lymphatic & Vascular Pathways

Supine – This positioning is the most commonly used when working with clients in the midst of a headache or migraine.

1. Standing at their side – Motion Palpation & Treatment for Repositioning the Shoulder Girdle. Place the client‟s hand on your chest (or alternatively, on your upper arm), using your arm that is farthest from them to hold it there. Hence, their arm is forward flexed 80- 90° and slightly abducted. Slip the fingers of your other hand under the clavicle. • Rock back and forth on your heels; lifting the clavicle up off the ribs &

brachial plexus (and lower it back down – lifting up and down several times). You are oscillating in an anterior-posterior direction.

• Note: your “motion hand‟ is the hand holding their wrist and moving the arm, while the other hand is your “listening hand‟

Hold the forearm gently, against your body/arm if possible.

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Now, palpate the motion of the clavicle at the A.C & S.C joints; the motion of the 2nd & 3rd ribs (and farther down if you wish). Also sense the motion within the tissue in general through the arm, upper thorax and neck. • Stabilize over the most lateral portion of the clavicle – the anterior

surface – and hold it still as you lift. This will stretch the A.C. jt. capsule. The same can be done with the S.C. jt., but here stabilize the manubrium. ‘Tug’ the sternal end of the clavicle free if the joint has been found to be restricted.

• Switch motion hand: tuck their arm at your hip/waist (that is closest to them). Continue rocking/oscillating, but now in a superior-inferior direction, while you palpate the G.H. jt. and other tissues as above, but now from this perspective. Note the quality & quantity of motion available in both directions.

Note: • An option available here while standing at their side, is to turn the client’s head towards you (30-

45⁰) and reach across with one hand, starting at their (contralateral) shoulder and sweep up from the humerus all the way to the base of the skull – when this hand is half-way along this path reach over with the other hand and follow the same path, repeating several times in a slow rhythmic manner. The client’s head should rock gently.

• You can do some good drainage work now, if you wish: while the client’s head is still turned towards you, sit down on your stool (while still at their side) and place your hand on the side of their head with two fingers in front of the ear and two fingers behind (the “Vulcun Live Long & Prosper salute”), the palm of your hand will be over the cheek-bone. Gently make a small circular motion around the ear, which should slightly move the external ear, repeating several times –

arm fixed and ask the client to gently push their shoulder down and then relax, and as they relax quickly lift the shoulder more in the superior direction. Reverse technique if the shoulder acts like it does not want to move inferiorly.]

If you feel that motion is restricted in either direction then perform PIR/MET appropriately. [I.e., if the shoulder feels it will not lift, then push it superiorly to the barrier, hold the shoulder and

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some clock-wise, some counter-clock-wise. Imagine the eustachian tube being slowly stretched and circumducted…, Then, slowly slide your hand down along the client’s jaw, ‘dragging’ on the skin slightly as you do so. Have the client relax their jaw so that the mandible shifts slightly laterally.

2. From the side of the client, therapist seated – Treating the Shoulder Girdle, Cervical Spine & Sub-occipital areas. Assessing & treating the AC and SC joints: Bend the elbow 90⁰ (with the triceps resting on the table) while the shoulder is abducted roughly 90⁰ [Not pictured here.] While holding just proximal to the client’s wrist Internally and externally rotate the Glenohumeral joint. With the other hand, place one finger (the third finger) just posterior to the AC joint and another (the index finger) just anterior to this joint. Note as you internally & externally rotate their shoulder how the clavicle moves on the acromium – encourage motion in any direction that movement seems restricted. Now, slide the two fingers down along the clavicle as you continue the motion – Till you place the fingers over the SC joint - note motion at this saddle join. If the joint seems restricted, then traction the arm ( hile the GH joint is at 90-110⁰ abducted) while circumducting the arm is small circles. Thus gaping & releasing the SC joint.

Now: - Gentle Oscillatory motion of the GH jt. in scaption – Compression-decompression of the articular surfaces reduces pain and stimulates articular cartilage repair. Increase motion into AC jt. & SC jts. - Bring Scapular motion into the mix. Slip hand under the scapula so that your fingers touch some of the spinous processes. With each decompressive motion have the SP (or Two) move into the finger tips. You can sense the quality of motion between a segment and its neighbours. Resisting, or assisting motion can help release some restrictions. “Push-Pull”

- Muscle tissues – address the pectoral muscles, all scapular muscles, rotator-cuff muscles, shunting muscles, paraspinals (T8 and up). Extra focus is given to the musculature that suspends the shoulder girdle from the cranium & spine: Rhomboids, Levator Scapular, Upper Trapezius, SCM, (along with the Scalenes holding up ribs one and two).

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- Vascular, Lymphatic, & Neural tissues: light drainage… (around ears, face, jaw, neck, & into upper chest).

- Also employ inhibition with very light and rhythmic “press-release” movement directed towards/over the cervical sympathetic ganglia, etc.

- Extremely light “tracing” of the carotid artery and jugular vein.

3. Therapist at the head of the table, therapist seated – Treating the cervical spine, cranial vault, face & jaw.

• Lift the head and generally assess the motions available in the spinal column and at occiput and C1. [More on this can be found starting on page ]

- Gentle lateral oscillations; or rotations (As you move up, access and treat). Small anterior glides with return can be done here. In the cervical spine seek greater mobility, and take your time to gently oscillate repeatedly, trying to free segmental joints.

Repetitive translations within joints’ pain-free range work best.

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- Upon reaching the sub-occipital space, gently traction the occiput with the finger pads, noting how easy (or not) it is to have your fingers sink in. Employ sub-occipital hold-release.

- Using M.E.T. on the O.A. joint: 1. Ask the client to relax their head as you tuck the client`s chin in for them. If resistance is felt, ask them to do it for you and then to relax.

2. Lift gently and slowly (you may sit or stand) till you reach the barrier of hard stretch. 3. Give the following instructions: “I will ask you shortly to take in a long slow deep breath; Keep your eye-lids closed (to avoid changes in light), but using just your eyes (with no conscious attempt at neck/head movement) try to look up into your eyebrows, all the time you are breathing in. Then I will ask you to breathe out and look down to your chin, relaxing and just let everything go.”

Each time the client looks up, resist extension at the OA joint, and when the client breathes out and looks down, take up any slack – but only what the eye & breathe give you! Do not push through! For Rotation of the A.A. joint, and for the lower cervical spine the following M.E.T. method works very well. - With the head held in forward flexion (making the facet joint immobile) you can isolate the effect to the A.A. joint. However it is useful for the lower facets as well. In either case, A) rotate the head towards the restricted side, to the pain free barrier. B) Place your hand on the opposite cheek bone (to the restricted motion), and ask the client, having taken in a deep breath, and only using their eyes, to look into the palm of that hand. Resist any rotation away from the barrier. C) Tell the client to now breath out and look away from your hand. Take up the slack by letting the head slightly roll past the previous barrier to a new one. Repeat 3 to 5 times. It is good to repeat once or twice back in the other direction to ensure that direction of rotation remains free.

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Remember, that the A.A. joint & the lower cervical spine (as with the upper Thoracics) respond well to indirect techniques.

With freer rotation proceed with the following:

• Stroke gently down several times along the SCM,

inhibiting muscle tension and encouraging drainage. Stoke just behind the SCM… over scalenes… continue around till your fingers run down either side of the SPs, down to T6 or so.

• This would be a good time to do some lymphatic pumping just above and just below the clavicle (lateral to the SCM’s attachment on the clavicle)

Turn your attention to muscular and connective tissues. Soft work is crucial. Work within the tissues mobility, to have them soften, and gain more mobility & motility.

• Rotate the head slightly and address again the vascular and neural tissues, with a focus on freeing them within their connective tissue sheaths. Inhibitory work is required for the cervical ganglion. With the head rotated slightly away, side-bend the head towards your working hand. This will soften/shorten tissues enough so that you now can get onto the anterior surface of the TVPs and lightly address the longus colli and other anterior recti muscles.

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Once again perform sub-occipital work, and periosteal massage to muscular attachment sites on the occiput (way up into the hair). Working gently but firmly over the temporalis muscle, around the ear, down into the jaw, while finishing each circuit with a gentle sweep over the jaw line and down the side of the neck to the subclavius area. Work back up to the superior cervical ganglion site, using a Vodder-like approach (i.e. small sweeps near the subclavius, then a few centimetres higher, but sweeping down the neck, and again, moving up while sweeping down, till you reach the ganglion) Repeat the circuit from sub-occipital to temporalis to jaw three times, at least.

Specific work on the TMJ can be added when indicated: compression-decompression; PIR for pterygoids; etc. Intra-oral work, however, should be done only between episodes and even then only with careful preparation, planning (for contingencies) and caution.

You can also work the ear itself at this point, as the external (and internal) is enervated by the Trigeminal, Facial, and Vagus nerves. Hence, once you reach the ganglion, as above, before going to the sub-occipital you may wish to gently work the ear.

Repeat all of the above on the other side of the neck and head: or when treating specific areas or tissues you can go from side to side, step by step…

Rock the head into slight extension (chin lifted slightly) and address the hyoid muscles.

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‘Sticky fingers’ and ‘Crushing’ Cranial Techniques

• Hold & Listen –with the client supine place your hands on either side of the cranial vault. Keep releasing your ‘hold’ till you feel only the finger pads in contact. Now, imagine that your fingers are ‘sticky’, and as you further lift the finger tips into extension, you ‘pull’ the skin and cranial structures with you. Stop and hold at the point where you feel that any more extension of the fingers would break contact. Use this ‘sticky fingers’ extension movement to increase your sensitivity.

Transverse and Sagittal Sinus Drainage:

And/ or

• Place your fingertips together, palms up, and make contact with the occipital bone – your finger pads running up the mid-line of the bone. And/Or, Keep the fingers in the position of the sub-occipital hold, and lift them up to the middle of the occipital bone, matching the sinus drainage…

Thumb tips meet at the posterior start of the sagittal suture. Gently pull the sagittal suture apart. Hold for several seconds, then move up one thumb width, and repeat… Pressure on or across the sagittal suture has shown to increase sagittal sinus drainage. Continue till you meet the frontal bone.

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Again, place finger nails of matching fingers touching each other and then lower finger pads running down the middle of the frontal bone to between the eyebrows. Pull apart, slowly release.

Hook each eyebrow and pinch top of the nose; pull apart, slowly release.

Frontal-Lift:

Move your hands till the radial edge of each index finger lies at the lateral border of the fontal bone. Lift. Hold. Lower.

Palpate each mastoid process. Feel for a gentle motion, as-if the two mastoid processes were slowly moving ever so slightly towards each other and followed by an outward pressure. ( external-internal rotation). Provide a slow gentle pulsating motion inward and up. (Compression & decompression of mastoid sinus; changing tension on tentorium/dura.)

Sphenoid Adjustment: cradling the head in our hands place your thumbs over the client’s “temples” (the sphenoid bone). Gently pull down towards the table till a slight resistance is felt. Hold, till release. (More like an intention to pull down…) Then, lift gently till a slight….

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Temporal bone release:

Place your thumb or fingers on parts of the external ear, close to the canal. Pull the ear canal in four directions, and finally pull canal gently laterally and down toward the table.

Gently massage the ear lobe, and outer ear.

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If you wish you may perform specific ear drainage now: Rotate the head a little one way – fork around the ear, holding the skin around the ear as you make slow circles with the ear. Go in both directions. Finish stroking down jaw line 3x; stroke down lateral neck 3x; ‘pump’ over subclavian junction with vena cava. Now repeat your way back up to the jaw.

“Crush cranium”

-- One hand over the frontal bone, one under the occiput. Gently squeeze the head, and slow release and try to pull apart (i.e. sticky palms). Do to the rhythm of deep slow breathing. Your breath out = crush, your breath in = lift. Repeat cycle numerous times.

-- Hands over temporal and parietal bones, on each side. Squeeze slowly (on your out-breath) and release slowly (on your in-breath). On the release pull the skin superiorly towards the vertex, then let it return. Repeat cycle numerous times.

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Working the Trigeminal Nerve at the Foramen (Note: the upper 2 are classic “sinus points”)

With index fingers find the trigeminal foramen in the eyebrows. Gentle circles, and then stroke up to hair-line. 3x. Repeat at maxillary foramen and mental foramen.

You can repeat this set over again, for several cycles.

CV4 = Compression of the 4th ventricle – used to induce a “still-point”

-hold the occiput between the thenar eminences. Feel for the respiratory movement. In the cycle, when it feels like the thenars are coming closer together “hold” that position – do not let the occiput expand….

Wait for still-point…. When the rhythm/cycle reasserts itself, let the movement happen….

1 2

3

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General Sympathetic Inhibition

Place finger pads of Index finger over orbital foramen, ‘ring’ fingers over the maxillary foramen, and then gently lie your middle finger onto the eyelids. (Contraindicated for clients wearing contacts. Ask!) Remain for several moments. After several seconds many clients will sigh and ‘let it all go’ possibly even falling asleep. Finish – Always place an ice-pack (wrapped in a hand-towel) under neck (from sub-occiput to C7/T1) “5 min. on; 5 min. off”

More on treating the Cervical Spine with Muscle Energy Technique:

Cervical Spine OA joint - It is best to precede treatment with a “sub-occipital release” [ii], which allows the therapist to gage 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. And to treat problems with sub-occipital muscles as well. Sub-Occipital Assessment… 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. Use slow deep breathing by the client as an assist. 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.

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Diagonal Glide through OA Joints (Movements slightly exaggerated for clarity)

1. Cup occiput in palms. Finger pads not in contact with C1 or any part of cervical spine. Head in neutral. Traction head slightly to disengage OA joints. 2. Move head diagonally, right hand towards left eye. End range reached when cervical spine begins to move. 3. Move head diagonally with left hand towards right eye. End range reached when cervical spine begins to move. Lifting the occiput through its left O-A joint. You may wish to shift back and forth from one hand to the other, as the joints are often hypomobile at first (i.e. “stiff”), but “loosen up” with just a few glides back and forth. You will then be able to get a more accurate appraisal of any impairment to motion at that specific joint. M.E. Sub-occipital Release - Lightly traction the cervical spine while the patient is supine. Lift the head slightly off the table and tell the client to let the chin tuck in as you draw the occiput to ward you, which flexes the OA jt (the ‘nodding motion). - Move or nod the head only till resistance, “the barrier” is felt. There should be no discomfort for the client. - There need be only a little flexion in the lower quadrant of the cervical spine as our focus of treatment is in the upper quadrants. A comfortable feeling of light stretch in the sub-occipital region is ok. - Support this position with one hand cupping the occiput and the other hand just above the forehead (i.e., just behind the normal hairline). Tell the client to relax.

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. - The head will usually follow the movements of the eyes (unless one consciously resists doing so). These highly proprioceptive loaded muscles should contract first prior to the larger muscles of the

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cervical spine engaging so as to protect the spine by co-ordinating the movements of (& stabilizing) 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’ without injuring the structures of the cervical spine. [i] This is for an extension lesion – the most common (usually due to a ‘foreword head’…) - Have the client take in a deep breath and hold it as the therapist then … - Tells the client to 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 let the clients activity of looking down move the OA into more flexion. Let their eye movement do the work for you! - Try to focus on not to having the whole cervical spine flex, but only let the occiput slide into flexion, which is seen by the chin tucking in a little further then 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.

• Note: This technique works for mild to moderate restrictions in the OA jt. • However the technique can often be more effective with major lesions of the OA if the side-

bending and rotation are also addressed. But this is enough for now. OA Held in Flexion… If you found that the client has a flexion lesion in the OA jt (i.e. the OA does not want to extend) then - • take the client into flexion, into ‘ease’ • Come back into extension till resistance is felt, then go a little back into flexion • Have the client breathe out & hold • Tell them to look down as you resist flexion (by resisting at the forehead) • Have the client breath in and look up simultaneously • Take up the slack/let the head move further into extension – repeat 3-5 times Motion Palpation Testing of the Atlanto-Axial joint When we have observed a loss of cervical rotation during observing AF-ROM, we need to differentially test for loss of range coming from the upper cervical verses the lower cervical spine. To do this we first note the range of motion when doing AF-ROM rotation of the cervical spine, recording the client’s approximate ranges in rotating left and right. We then do the following test to see how much loss of motion may be due to, if at all, the Atlanto-Axial joint. (Remember, the A-A joint is responsible for 50% of normal rotation of the cervical spine: 40-45° of rotation in each direction from neutral.). Compare any loss, if any, with what was seen in PR-ROM (see immediately below) and then calculate how much of the loss is from the A-A joint and how much is from the lower cervical spine. (Explanations of such calculations are done below after the testing has been described.)

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To test the Atlanto-Axial joint, which is between C1 and C2, we again start with the client’s head cupped in your hands. (Which also may be were their head already is if you have done the OA joint testing as above) 1. AA Joint Testing Starting Position

Cup head in palms of your hands. Passively (PR-ROM) test the full rotation available to the cervical spine as a whole. Note total ranges. Do not apply overpressure!

Perform PR-ROM Testing

Rotate head & cervical spine to the left and then to the right. Client here shows restriction to rotation to the left. Take the cervical spine into flexion by first tucking the chin in, (which also takes up the slack in the OA joint), and then move into the full flexion available in the cervical spine as a whole Full flexion takes up the slack within the facet joints of the lower cervical spine, which will restrict movement coming from them during this test. Notice in the demonstration pictures given here how the therapist stands up when forward flexing the cervical spine. Standing allows the therapist to easily and securely hold the weight of the client’s head, and it prevents excessive extension of the wrists as would occur if one remained seated. 3. Positioning for AA Joint Testing

Starting from neutral: Tuck chin in flexing OA joint; and continue flexing cervical spine till end range. This locks all joints but the AA joint.

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Ask the client if they are in any discomfort. If not, then proceed by rotating the head to the left, for example, and note the range. (fig. 149) Then rotate to the right. (fig. 150) Note the approximate degrees of motion available to each side and compare with ranges seen in AF-ROM and PR-ROM. You can then calculate the percentage (or approximate degrees) of motion lost from the A-A joint in comparison to the lower cervical spine. 4. Testing ROM of AA Joint

Rotate head to left. Note range. Rotate head to right. Note range. Should achieve roughly 45° in either direction.

Calculating Loss of ROM in AA Joint Compared to Lower Cervical Joints

1. If during AA joint testing we get less rotation then normal (on either side, or both) then the AA joint is probably involved in the client’s loss of rotation.

2. If this loss equals the total loss seen in PR ROM testing then the AA joint is fully responsible for the loss and it is the area to work.

3. If it is only part of the loss as seen in PR-ROM tests then both the upper and lower are contributing to the loss of rotation. (We will discuss specific testing for each level of the lower cervical spine shortly.)

4. If the AA appears normal, but P R-ROM had showed loss of rotation, then that loss should be coming from the lower quadrant (the client’s facet joints and their operative musculature).

Let’s treat the AA Joint - M.E. Atlanto-Axial Release • 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. 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).

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• Instruct the client to take in a deep breathe & 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, lets 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.[i]

- 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 together, and then try this AA joint technique again Now for the Lower Cervical Spine Starting Position for Lateral Glide

Picture shows how head is being supported by therapist’s thenar eminences & how the fingers support & palpate within the lamina groove. The motion available is not only palpable, but is usually visible as well. We can measure it by eye by looking at the amount of movement the chin undergoes as it moves left and right during our translating of the client’s cervical spine. The midline used to measure from is provided by the sternum, or more precisely

the sternal notch. Motion side-to-side should appear symmetrical. A line running between the client’s eyes, through the nose and the chin should be seen to move perpendicular, shifting slightly to the left and to the right of the sternal notch. Restrictions are seen when the chin move less to one side then the other, producing asymmetry of motion. Restrictions are felt by the palpating hands, often as if the vertebra is tethered (like with a rope) and when it tries to go in one direction it stops short. It has ha firm fell to its end-range. Ensure that you are moving the whole head laterally, and are not actually sidebending the head. In other words, ensure that the head remains perpendicular. Think of the head as always remaining at 90° to a straight line running from one shoulder to the other. Now move up one level, with the fingertips in the lamina groove adjacent the TVP’s of C 6. Translate through the facet joints of C6 and C7. Continue to work your way all the way up testing all the segmental levels up to C2-C3.

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We may find restriction at only one level, or at several. We have here tested for restrictions in neutral. If any restrictions are found then we will next test the lower cervical spine in flexion and in extension.

Translating to the Left Translating to the Right

1. Lateral Translation Lower Cervical Spine Starting Position

161 The therapist is holding the spine in neutral.

2. Lateral Glide Right – Testing Left Sidebending

The therapist translates lower cervical spine right

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3. Lateral Glide Left – Testing Right Sidebending The therapist translates lower cervical spine left.

The positive sign in motion testing is the observation of asymmetry of motion as is noted by the motion of the chin. Hence, for the lower cervical spine we will be looking for motion asymmetry at each segmental level as we translate each level from one side to the other. However, it is possible that the client could experience pain during such passive motion testing, but that is not a positive sign; asymmetry of movement side to side is the key positive sign in any motion palpation.

Summary of Findings While Testing in Neutral: Position of

Spine: Direction of Translation

Sidebending to the:

If Restricted the Lesion is:

Side of Lesion

Neutral To the Right Left Unknown Unknown Neutral To the Left Right Unknown Unknown

Restrictions Seen While Translating in Flexion: Searching for Extension Lesions When we test using translation while holding the cervical spine in flexion we will be looking to see if a facet will not close or extend: We flex the neck a little more then half way towards full flexion and we then translate left and right. We do not fully flex the neck otherwise we would not have enough slack left in the joint capsule to be able to move laterally, (due to the stretched joint capsules restricting movement). Therefore, with the neck in some flexion, but not full flexion, we can still translate. 1. Testing in Flexion

Holding head with finger pads on C7. Translate left & right

This requires both facets to be slightly opened/flexed at the level we are testing. What is going to be most restrictive to lateral motion (sidebending) here is if a facet will not close or extend. In fact, the restricting facet that is closed/extended will actually exaggerate the asymmetry seen in neutral when we translate side to side. Therefore, the positive sign of an impairment of a facet to extend or to close is (increased) asymmetry in lateral translation when the spine is held in flexion. We will see that the chin

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moves less in one direction then another, and we feel a firm block to further movement laterally at that level. If for example translation is done while the neck is flexed, and we find even greater restriction when translating left, then the dysfunction is on the left side: C6-C7’s facet on the left is fixed closed (or, is in extension). It will not open/flex to allow sidebending to the right.

Summary of Findings for Impaired Flexion: Position of


Sidebending to the:

If Restricted the Facet is:

Side of Lesion

Flexed Left Right Extended On the Left

Flexed Right Left Extended On the Right

When the cervical spine is tested while in flexion the extension impairment is on the same side to which that segment is being translated towards.

Restrictions Seen While Translating in Extension: Search for Flexion Lesions Let use an example where we still have a restriction when translating left while testing in neutral. - However, let us say that in flexion the translation left becomes less affected as it was then when done in neutral, and so movement left and right appears more symmetrical. - - - We then get a negative finding when testing in flexion. This then implies that the left facet will in fact open. - Therefore, we will then proceed to test lateral translation while the neck is in extension. Testing Lateral Translations in Extension

Lift client’s neck into hyper-extension. Safer for client & easier for them to relax then having head off table. Stabilize with finger pads the superior vertebra of a motion segment (and hold all above still). Translate left and right looking for symmetry. - When translating in extension we are investigating whether

the facets will go into extension (will close) or not go into extension (will not close); i.e., a joint is stuck in flexion. - When translating at the C6-C7 level while the neck is extended a limitation in translation is found when going to the left, (while free when going to the right). We may now even see more asymmetry then was seen in neutral translation. - Remember that translation to the left requires the facet on the right to close (as the segment is sidebending right). - Therefore the dysfunction is due to a facet that will not close: the facet on the right side of that spinal motion segment is being held flexed/open and will not extend or close. We can conclude then that as a rule when finding a restriction translating while holding the cervical spine in extension is that we find: 1) “Flexion lesions” (facets that are held open/flexed)

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2) The dysfunction is on the opposite side to that which the motion segment is being translated towards.

Summary of Findings for Impaired Extension : Position of


Sidebending to the:

If Motion is Restricted the Facet

is:

Side of Lesion

Extended To the Left Right Flexed On the Right

Extended To the Right Left Flexed On the Left

When the cervical spine is tested while in extension the flexion impairment is on the opposite side to which the segment is being translated towards: e.g. restriction translating R = lesion is on the L

M.E. Lower Quadrant Release Turing 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

• If the facet is not open, or will not open, then it is also being held side-bent & rotated to the right and will resist side-bending & 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 in order to see if there are ‘facets stuck closed’ (are locked in extension).

• The facet is extended side-bent & rotated R. (ERSR) 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.

• We have to slowly flex the vertebrae one at a time till we feel that movement’s force reaching that level.

• 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).

• We will then rotate the spine till we find the point of resistance.

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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. Now, with the one hand still holding at the site of restriction take the head and lower it as much as possible. 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. Gently side bend the spine 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 – where we found it would not open. The therapist ‘follows’ the patient’s eyes when they look left, 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 flexing through the lesion site and flexing vertebrae below. • Repeat two or three times. • Retest 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 it really is not. Especially if the therapist views it as

palpation: motion 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

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Group Dysfunctions or “Rotoscoliosis” of the Cervical Spine Finding the Problem…

• The dysfunctions above have been segmental dysfunctions that occur between two vertebrae. • We need to now understand how to treat group dysfunctions.

Group dysfunctions have three or more vertebrae all held side-bent and hence rotated to one side or the other. We will be able through our testing to clarify if they are successive flexion lesions or impairments, or successive extension lesions.

- Based on what we have discussed above we can say that if they are flexion lesions (fixed open) then the vertebrae affected bend & rotate away from that lesioned side.

The restriction is seem most clearly when we translate in extension and find several vertebral segments restricted.

- Alternatively, if they are extension lesions then the vertebrae are bent and rotated toward the side with the lesions.

The restriction is seem most clearly when we translate in flexion and find several vertebral segments restricted.

Let us use the example of the cervical spine as a whole is curving off to the left, is side-bent left.

• When we translate, in neutral, in flexion, or in extension, several segments will all resist lateral translation. In this example, to the right, and this restriction is clearest when done in flexion. Therefore, we have a group dysfunction: several vertebrae are ESBL (held in Extension and Side-Bent to the Left)

Treating the problem…

• As we have been doing all along, take the spine where it wants to go, in this case, the Starting position is to let those segments be extended and sidebent left.

• Now, from this position of ease move the head and spine towards the restriction; --- First, flex from below the restricted vertebrae till you feel resistance, when you feel the barrier, than back- off slightly. -- Second, now slowly move towards right sidebending. Stop when you feel resistance, back-off slightly. (Note: since sidebending and rotation are coupled motions both will be happening at the same time.)

• Have the client look to the Left as they slowly breathe in, while you resist the client’s gentle effort to side-bend (“from the top of their head”) further towards the left. Hold for a count of 5. Tell them to breath out, look right and relax. Let the head move/take up the slack. Do 3-5 times.

• To treat this more effectively (or if the above is not getting you the results you hoped for) you can also resist rotation left and then let the head roll right when they relax and look right. Alternating between resisting side-bending and then rotation movements to the left will increase the effectiveness.

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Even further effectiveness can be had by having the client look up – try to go into extension - and take the cervical spine segments into flexion when they relax and look down… Doing all three: 1. Look Left…. relax, take into further sidebending. 2. Look Left… relax, take into further rotation. 3. Look up… relax, take into further flexion… Repeat this pattern at least twice.

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