RU2845605C1 - Method for correction of cervical spine (cs) dysfunction - Google Patents

Abstract

FIELD: medical science.

SUBSTANCE: invention refers to medicine, medical rehabilitation, manual therapy, orthopaedics and neurology. Doctor determines the mobility range in the joint at the level of C0-C1 in the cervical spine (CS), laying the bases of the forefingers on the transverse processes of the C1 vertebra of the patient, fixing them, and then the patient’s head performs the movements of lateroflexion – inclinations to the right and left. If the muscle tension is felt under the finger or fingers when moving right and left with limited volume of the corresponding movement direction, the doctor states the presence of a muscle block (FB) at the level of C1, and its sides are on the right or on the left. Further, the doctor performs a passive hand inclination of the patient’s head towards the detected FB with fixing the C1 transverse process from the detected FB with a base of the respective index finger. Patient in this position of the head turns both eyeballs towards the detected FB in C1 to the maximum possible angle of view and, fixing the gaze, inhales and exhales in this position 3 times at a comfortable pace. Patient then turns both eyeballs and fixes his/her gaze opposite the detected FB in C1 to a maximum possible visual angle and inhales and exhales in this position 3 times at a comfortable pace. Then the patient returns the eyeballs to a normal middle position; the doctor passively returns the patient’s head to the middle position as well. Repeating the patient's head passive inclination towards the detected FB in C1 and gaze movement 2 more times, then checking the mobility range in the joint at the C0-C1 CS level, and while saving the FB, all described manipulations are repeated until the detected FB is removed in one procedure. Doctor performs manipulations standing behind a patient sitting astride a chair, or sitting behind a head of a patient lying on his/her back.

EFFECT: method provides the detection of biomechanical disorders in the craniovertebral region due to the manual diagnostic procedure, improving the blood supply of the upper spinal cord, cerebellum, posterior part of the brain, improved vertebral blood flow ensured by eliminated irritation, normalized mobility in the atlantooccipital junction (AJ) and balanced compensatory motor disorders in the FSU at underlying levels.

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Description

The invention relates to medicine, medical rehabilitation, manual therapy, orthopedics and neurology, and can be used in manual diagnostics and therapy centers, specialized hospitals and outpatient institutions, health resort organizations of the corresponding profile, as well as by patients independently, at home in cases of dysfunction of the atlantooccipital joint (AOS, C0-C1) in the cervical spine (CS).

Craniovertebral dysfunction (CVD) is one of the main causes of cervicalgia and cervicogenic headache (CH), which occurs against the background of impaired biomechanics of the spine, myofascial dysfunction with the formation of local muscle spasm and trigger points and occupies a leading position in the structure of the most common causes of disability. 70% of patients with pain syndrome in the cervical spine simultaneously experience headache, but only in 18% of cases it is considered a consequence of neck pain. A number of authors indicate that 15-20% of patients have chronic headaches of a cervicogenic nature. Periodically, 40-70% of adults in the population complain of pain in the cervical spine (https://pudp.ru/cranio_dysf).

The cervical spine region has significant anatomical features for the occurrence of pain syndromes. Thus, the cranial-vertebral joint is most developed in humans due to upright posture and head elevation. The craniocervical segment has the greatest range of motion in the cervical spine, which is associated with the structural features of the atlantoaxial joint (AAS) or lower head joint (according to V.P. Vorobyov). There are two motor segments in the cervicoccipital region: the atlantooccipital (AOC, C0-C1), or upper head joint, and the AAS (C1-C2), or lower head joint. Together they form the cervical-occipital motor segment (COMS), in which up to 90% of the useful range of head movements, including rotational ones, occurs. The vertebrae of the craniovertebral region (CVR) also provide protection for the spinal cord and are a powerful reflexogenic zone.

The AOS is formed by two condyles of the occipital bone and the concave superior articular fossa of the atlas (C1). Both pairs of articulating surfaces are enclosed in separate articular capsules, but move simultaneously, forming a single combined joint. It moves around two axes: the frontal and the sagittal. Nodding movements, i.e. flexion and extension of the head forward and backward (expression of consent), are performed around the first, and tilts of the head to the right and left are performed around the second. The sagittal axis is slightly higher with its anterior end than its posterior end. Due to this oblique position of the axis, a slight rotation of the head in the opposite direction usually occurs simultaneously with the lateral tilt of the head.

Each of the two articulations of this region has its own ligaments that stabilize and provide some mobility. In addition, several external ligaments that are not related to the CVO but are adjacent to other parts of the spine act as stabilizers. The atlanto-occipital segment (AOS) provides flexion/extension of 23-24.5 degrees and lateral flexion of the skull of 3.4-5.5 degrees. Among the 90-degree rotation capabilities of the cervical spine, the AOS makes the greatest contribution (from 25 to 30 degrees), and the flexion/extension capabilities range from 10.1 to 22.4 degrees. Supraphysiological movement or excessive force applied to this region can cause various types of injuries.

Pathological conditions of the CVO leading to its dysfunction can be divided into congenital and acquired. Congenital anomalies of the CVO include the most common ones - aplasia or hypoplasia of the posterior arch of the atlas, developmental anomalies of the odontoid process C2, platybasia - flattening of the base of the skull, Kimmerli anomaly (the presence of an additional bone arch in the structure of C1, limiting the movement of the vertebral artery and causing its compression syndrome). In 26% of cases, the cause of cervicogenic headache are congenital anomalies of the CVO.

Clinical manifestations of congenital anomalies of the craniovertebral junction (joint) mainly appear at the age of 20-40. The provoking factor of their onset can be previous upper respiratory tract infections with a strong cough, traumatic brain injury (TBI), injuries of the cervical spine, professional loads on the craniovertebral junction, stress.

Acquired disorders of the foramen magnum include pathology of the foramen magnum due to deforming osteitis (Paget's disease), rickets, rheumatoid arthritis, osteoporosis; atlantoaxial instability due to spinal injuries in the cervical spine or TBI (during road accidents, falls, diving), including birth injuries, osteomyelitis, tumor processes in the foramen magnum, and a number of infections.

Neck pain and headaches caused by it are common due to prolonged work at the computer, repeated neck bends, postural disorders, or a combination of these factors. Neck pain is associated with the gradual development of degenerative changes in the spine. Sudden onset of neck and head pain is often associated with sharp forward or sideways bends, neck twisting, or a combination of these movements. If the ligamentous apparatus is damaged, neck and head pain can occur even after sneezing due to severe adaptive muscle spasm. Also, one of the most common causes of acute neck pain radiating to the head, shoulder, arm, forearm is a herniated disc, subluxation of the facet joints.

Violation of the biomechanics of the craniovertebral spine leads to spasm of the muscles of the head and cervical spine, extravertebral muscles, contractures of these muscles, the occurrence of latent trigger points in them (muscular, fascial, muscular-ligamentous, ligamentous-bone), regional muscle imbalance. Functional muscular, fascial, muscular-ligamentous, dural craniovertebral blocks C0-C1, C1-C2 develop, irritative-reflex syndromes arise, such as muscular-tonic (muscle spasm, pain); myofascial (muscle spasm, formation of painful muscular seals, active or latent trigger points in tense muscles); painful, since foci of pathological nociceptive impulses appear and increase. As a result, cervicocranialgia, cervicalgia, cervicobrachialgia, and cervicopectalgia develop (the last two syndromes occur with pathology in the lower cervical spine).

The CVO and, in particular, the C0-C1-C2 level, is a strategic zone due to anatomical muscle connections. For example, a decrease in the tone of the lumbosacral muscles is associated with the presence of a functional block of C0-C1, the functional block of the CVO may be accompanied by secondary blockades of the sacroiliac joint (SIJ). Restrictions of the occipital junction can lead to pain syndrome, general muscle hypertonus, and impaired cerebrospinal fluid dynamics. With a blockade of the CVO with limited movement of the atlas, vestibular dysfunction, secondary blockades of remote segments, and twisted pelvis syndrome are observed.

Long-term pressure on the cranial extension of the spinal cord protruding near the opening of the skull, on the nerve pathways passing through this place, as well as on the spinal cord, which begins at the upper edge of the atlas, leads to distortions of nerve impulses going from the brain to the body and back. It is at the level of the atlas in the upper third of the cervical section of the spinal cord that the vasomotor center is located, which controls intracranial pressure. The free flow of cerebrospinal fluid, a volume of about 125-150 ml, which constantly circulates in an adult, is also disrupted due to long-term pressure on the spinal cord, which leads to severe disorders.

An obligatory symptom of CVD is headache. Patients complain mainly of unilateral headache, often occurring after sleep. Head movements, especially downwards, provoke pain. Headache with predominant localization in the occipital region spreading downwards to the shoulders is monotonous, squeezing in nature, increasing with emotional stress, or pulsating acute with retrobulbar irradiation and a feeling of squeezing out the eyeballs. It increases with coughing, sneezing, laughing according to the type of trigeminal neuralgia, migraine. Often accompanied by facial pastosity, usually in the morning.

Depending on the involved CNS structures, the following symptoms are mainly noted as a manifestation of vertebral artery syndrome: unsteadiness when walking, difficulty swallowing, weakness in the limbs, blurred vision, flashing spots before the eyes, syncope. With CVD, dizziness may be observed, often non-systemic, hearing loss, hearing loss. One of the main syndromes is loss of balance with a sudden change in head position, especially when moving from a lying to a standing position (resembles vestibular ataxia).

Instability in the CVO may be accompanied by chronic dynamic subluxation in the AOS and AAS. On the side of the subluxation (posterior displacement of the lateral mass of the atlas) moderate atrophy (dystrophy of muscle fibers) is observed in the muscles, and on the opposite side - hypertrophy of muscle fibers (Skorobogach M.I., Liev A.A. The role of fascia in the pathogenesis of myofascial pain syndrome of the neck and shoulder girdle in children: clinical and anatomical experimental studies // International Neurological Journal. - 2009. - 4 (26). - 105-110).

The symptoms of direct damage to the AOS include the following (https://studopedia.ru/10_30687_atlanto-oktsipitalnoe-porazhenie.html):

- headache in the occipital region, bi- or unilateral,

- occipitofrontal headache, spreading from the back of the head through the crown to the forehead, usually unilateral, but can be bilateral,

- headache like a "tightening band" around the head and forehead,

- frontal headache,

- pain "behind the eyes" or unilateral behind one eye,

- difficulty focusing the eyes and, in extreme cases, some degree of hemianopsia (rare),

- a zone of hyperesthesia on the scalp, “it hurts to comb your hair with a comb.”

Examination of such syndromes includes clinical-neurological, vertebroneurological, manual, osteopathic and paraclinical studies, which allows to assess the degree of vertebrodynamic disorders, determine the type of pathobiomechanical and pathobiokinetic disorders, identify a non-optimal motor stereotype, postural muscle imbalance, hypermobility, instability, functional blockades of the spinal motor segments (SMS), reflex syndromes and clarify the clinical diagnosis.

Manual examination includes visual diagnostics, analysis of the volume of active and passive muscle movements, the volume of passive movements in the CVO, joint play, palpation, and identification of trigger points. In this case, they determine the static-dynamic dysfunction of the spine, non-optimality of statics, displacement of the projection of the general center of gravity relative to the median plumb line forward, backward, and to the sides, taking into account the distance between the feet, assess the position of the head in space and determine regional postural muscle imbalance; identify myoadaptive syndromes (changes in the motor stereotype) when changing the posture in the affected part of the spine, with its other sections compensatorily changing their location. They also determine a non-optimal dynamic stereotype, an atypical motor pattern (they evaluate the simultaneity and smoothness of movements, sufficient volume, the absence of additional movements in neighboring regions); advanced or delayed inclusion of the motor pattern. The volume of active movements is determined, which provides information on the active contraction or limitation of the contractile ability of the neck muscles by active trigger points. When analyzing the volume of passive movements in the CVO, joint play, the ability of muscles to lengthen and the presence of pathobiomechanically significant functional blocks (FB) of the PDS are established. The absence of participation of the vertebra under study in dynamics (in the movement that provokes pain) and the presence of "stopped movement" in 3 planes in statics indicate the presence of a pathobiomechanically significant FB of the PDS that disrupts the dynamics of the spine section under study.

Determination of the sensitivity of the pericranial muscles is revealed by palpation and light rotational movements of the second and third fingers of the hand, as well as by pressing, which allows one to detect tension and muscle soreness, to recognize by palpation a tense muscle knot and compaction of a bundle of muscle fibers, characteristic of trigger points.

To identify myofascial trigger points (MTP), three types of palpation are used: superficial (using a fingertip to cause subcutaneous tissue mobility when the patient's skin slides over the muscle fibers); pinching (by grasping the belly of the muscle between the thumb and the other fingers), which often reveals a local spasmodic reaction; deep, when, for example, a "jump symptom" is detected. In this way, it is customary to identify dense painful muscle cords, active (ATP) and latent (LTP) trigger points: muscular, fascial, muscular-ligamentous, ligamentous-bone and capsular.

LTT, like ATT, can cause increased muscle tone, muscle tension, muscle shortening, resistance to the process of muscle stretching, which is characterized by a decrease in its mobility, significant impairment of motor function, and the development of an atypical motor pattern. Impairment of motor functions caused by a trigger point includes spasm of other muscles, weakening of the function of the affected muscles, and impairment of their coordination. A muscle with a trigger point has increased sensitivity, slow relaxation, and increased fatigue. An active key trigger point in one muscle can enhance an active satellite trigger point in another muscle. This leads to an overload of other muscles and the spread of the pathological process from one muscle to another. When the suboccipital muscles are affected, there is a limitation of head mobility in the direction opposite to the affected deep neck muscles (the inferior oblique muscle of the head and, possibly, the large rectus capitis posterior muscle), which are shortened due to the presence of LTT. There is a local muscle spasm, pain in the posterior cervical region, myogeloid compactions in the upper portion of the trapezius, semispinalis, epicranial, splenial and suboccipital muscles. Objective signs of functional pathology of the CVO are MTT in the upper third of the sternocleidomastoid muscle, in the extensors of the head and neck, at the attachment sites to the bones of the occiput, atlas and axis. MTT are formed in segmental muscles (rotators, multifidus and intertransverse muscles), and then in individual muscles, myotomes.

Assessment of pain in the neck and head is carried out using the visual analogue scale (VAS) for neck pain, the LANNS pain scale, the pain questionnaire, the short form of the McGill pain questionnaire, the index of disability due to neck pain, and the Oswestry questionnaire.

X-ray examination allows us to separate functional blocks that disrupt the dynamics of the region (mainly joint blocks) and statics (mainly muscle blocks). Arthrosis of the atlanto-occipital (AOC) and AAS (complication of FB) determined by X-ray imaging leads to limited mobility in the joints, fascia, affects the tone of muscle tissue, which leads to overload of the corresponding joints.

Radiographic diagnostic criteria for atlantooccipital dislocation (AOD) are not clearly defined because no available method is perfect. The Treynelis classification divides AOD into three groups: anterior displacement – type I, axial distraction – type II, posterior displacement – type III, but this method does not take into account coronal displacement. The Powers ratio, measured in the midsagittal plane, compares the distance from the basion to the anterior cortex of the posterior arch of the atlas with the distance from the opostion to the posterior cortex of the anterior arch of the atlas. The normal value is less than 0.9, higher values correspond to AOD type I, but are less sensitive for AOD types II or III.

The X-line method, which is more sensitive than the force ratio in identifying Traynelis type II and III AOD, involves drawing two lines in the midsagittal plane and assessing the anatomical relationship of the CVO on the radiograph. Another way to identify AOD is to measure the basion-odontoid process interval and the basion-axis interval, with the Harris method using these two measurements together. Finally, measuring the occipital condyle-C1 interval is specific for Traynelis type II injuries and has been validated in the pediatric population. As mentioned above, the clinical and radiographic manifestations of AOD are varied, so a high index of suspicion of the physician is important for diagnosis and prevention of secondary injury. There are also some specific radiographic methods for determining AOS mobility, in particular, in children (e.g., RU 2428116 C1, 10.09.2011, O.N. Markov).

During manual diagnostics, when palpating the depth of the "groove" under the occiput, "more space" is found under the occiput on the side of the posterior displacement of the occiput. Less space on the side of the anterior displacement of the occiput and a "hard sensation" when the examiner's fingers encounter the transverse process of C1, which is located relatively behind. Limitation of flexion and extension of the occiput is determined, palpated during "balloting" ("nod-nod"), the absence of even minimal normal, passive lateroflexion and rotation in the AOS, assessed by palpation. Limitation of active flexion/extension of the head may also be detected, but it is usually masked by other segments of the neck.

Additional examination methods include consultations with an ophthalmologist with ophthalmoscopy (fundus), an otoneurologist with audiometry, and in the case of vertebral artery syndrome – REG with functional tests, transcranial Doppler sonography, and duplex examination of extracranial vessels.

Observation of subclinical forms of CVO anomalies without or with minimal complaints and stable, minor clinical manifestations is carried out by a neurologist, manual therapist and rehabilitation specialist. The presence and progression of neurological symptoms with instability or compression of the spinal canal is an absolute indication for neurosurgical intervention.

There are known neurosurgical methods for stabilizing this joint, for example, the method of anterior transoral atlanto-occipital stabilization (RU 2685806 C1, 04/23/2019, Shkarubo A.N. et al.), which, however, are invasive and can lead to the development of various postoperative complications.

Traditional treatment of CVD includes the use of NSAIDs, local anesthetics in the form of injections, patches, corticosteroids in the form of ointments and gels, muscle relaxants, nootropic agents and chondroprotectors, neurotrophic vasoactive drugs. Manual therapy, exercise therapy, massage, balneotherapy and magnetic therapy, electrophoresis with novocaine and hydrocortisone, therapeutic ultrasound and laser therapy, acupuncture, shock wave therapy (SWT), kinesiotaping of the neck and upper shoulder girdle are also used.

Manual therapy is indicated for functional mobility disorders in joints and soft tissues of the joint system. Manual therapy is absolutely contraindicated in patients with identified joint mobility anomalies in the presence of focal neurological symptoms, unstable clinical picture with frequent relapses. Joint mobility anomalies imply an organic component of the restriction. In case of increased mobility in the joint with a painful reaction of periarticular tissues, we are talking about organic instability, which implies refusal to use articulation and manipulation techniques. The use of soft tissue, reflex, muscle-energy, therapeutic techniques is indicated if they lead to stabilization of this area, increase its recovery potential, if the direction and type of disorder in the joint system and their impact on neural structures are taken into account when performing therapeutic techniques.

Relative contraindications for manual therapy of the CVO are asymptomatic anomalies of the CVO and cervical spine (Kimmerly, Arnold-Chiari anomalies), ankylosing spondylitis (Bechterew's disease), herniated intervertebral disc in the cervical spine in the acute period with severe pain syndrome, decompensation of diseases of internal organs, malignant neoplasms, osteoporosis.

In manual therapy of the CVD, the principle of interdependence (myofascial chains) is used, which implies that any structural imbalances that occur in any part of our body, for example, tension in the pelvis, legs, spine, upper thoracic aperture, due to extensive connections through the skin, muscles, fascia, etc., tend to be reflected in the form of disturbances in the suboccipital region. When the body balance is disturbed, the upper cervical spine and craniovertebral junction always react, leading to a forced position of the head. This adaptation, occurring in the suboccipital region, is expressed in subluxations and tensions (and, accordingly, pain) in the muscles of the head and neck.

In case of FB with CVO, soft tissue mobilization techniques are used (kneading, stretching, rhythmic traction, inhibition, vibration), stretching and massage of the trapezius and posterior cervical muscles, non-specific rotational muscle mobilization, stretching and massage of the suboccipital muscles, traction mobilization of the paravertebral muscles, inhibition of the suboccipital muscles, stretching of the lateral and posterior groups of neck muscles, soft tissue mobilization of the shoulder joint and scapula.

Post-isometric muscle relaxation (PIR) is performed on the following muscles: neck rotators, upper and lower portions of the trapezius muscle, pectoralis minor muscle, lower oblique muscle of the head, supraspinatus and infraspinatus muscles, short extensors of the head, subscapularis muscle, deltoid and pectoralis major muscles.

Techniques of joint mobilization and articulation include mobilization for lateral bending - nodule C0-C1, mobilization for flexion - nodule C0-C1, mobilization for extension - nodule C0-C1, mobilization for lateral bending in the mid- and lower-cervical spine, mobilization of the shoulder joint with limited internal rotation, mobilization of the shoulder joint by ventral displacement of the lateral angle of the scapula against the humeral head.

Specific manipulation (trust) techniques include thrust, high-speed, low-amplitude – manipulation of the AOS for traction, manipulation of lateral tilt at the cervicothoracic junction, non-specific rotational manipulation, specific manipulation of lateral tilt in the mid-cervical spine, specific manipulation of rotation in the mid-cervical spine, manipulation of the ACO (atlanto-occipital joint) for lateral tilt, flexion, manipulation of C1-C2 for rotation.

At the same time, sharp head tilts and turns, headstands, and somersaults are undesirable for patients with CVD. It is not recommended to engage in traumatic sports and forced loads, avoid prolonged forced positions and carrying weights over 5 kg, limit the weight (no more than 3 kg) when lifting objects above the shoulder girdle in everyday life, limit work with equipment that creates low-frequency vibration, regular exercise therapy is necessary to strengthen the muscles of the neck and shoulder girdle.

If left untreated, there are chronic pains in the back of the head and back, impaired mobility of the head and shoulders, migraines, severe weather sensitivity, heaviness and aching pain in the arms, numbness in the arms, fatigue in the morning, cramps in the arms and legs, increased sensitivity to noise, decreased concentration, dizziness, impaired balance, night pain, paresthesia of the arms, tinnitus, "flies" in the eyes, intolerance to bright light, watery eyes, cold hands, night sweats, memory impairment, bleeding gums, changes in smell and touch (impaired sensitivity of the tongue and pharynx), increased sensitivity or hearing loss, etc. Gait and posture are impaired (https://mc-atlant.ru/articles/bolezni-pozvonochnika/rotatsionnyy-podvyvikh-atlanta/).

Manual therapy is known to use soft techniques (https://novelclinic.ru/articles/nestabilnost-shejnyh-pozvonkov), which allow to release the spinal cord, vertebral artery, nerves from compression. The procedure is carried out at the stage of remission. Manual treatment is carried out by a qualified specialist after examination by a neurologist. 5-6 sessions are enough to restore the normal position of the vertebrae, eliminate neurological disorders, and normalize cerebral circulation. With more frequent procedures, the ligaments can be overstretched, which threatens to imbalance the spine.

A specially selected exercise therapy complex by a doctor will also help strengthen the neck muscles, increase the elasticity and strength of the ligaments. Exercises should be performed regularly so that the muscles support the discs and vertebrae, relieving the load on them, stopping destruction. After surgery and injury, exercises are carried out under the supervision of a doctor, then at home. The treatment program is supplemented with massage, a protective regime (at the acute stage of the disease).

Various manual techniques for releasing the AOS are known (https://vk.com/video577414510_456239020). Mobilization of other levels of the neck or the cervicothoracic junction and upper thoracic region may be needed to prevent recurrence if the patient has limited neck rotation. Referral to an ophthalmologist/eye specialist may be necessary if the patient's neck/head posture is affected by vision imbalance. Also, monoaural deafness/hearing impairment needs attention in such cases.

A method for correcting dysfunction of the cervical spine and other muscle blocks by performing manual techniques on the cervical spine is known, previously developed by the co-authors of the invention (RU 2823181 C1, 19.07.2024, Samorukov A.E., Mikhalev V.S., Krivo Yu.A., Budylin S.P., Fesyun A.D.). To do this, first carry out a diagnostic test - flexion, determining with its help, due to the blocking of which segments the mobility of the spine suffers. Standing behind the patient sitting astride a chair, place the thumbs of both hands, respectively, on the left and right over the transverse processes of the vertebra located below the examined vertebral segment. Then the patient performs active segment-by-segment forward flexion of the head and body. When the phenomenon of asymmetric advancement of the thumb cranially on one side, compared to the other side, occurs, the presence of a muscle block at the level of this segment is established with the implementation of flexion due to the higher segments of the spine. Using the diagnostic flexion test, all segments of the spine are sequentially examined in the direction from bottom to top or from top to bottom, establishing muscle blocks at the level of the corresponding segments.

Next, to perform the therapeutic manipulation at the C2-C3 level, the physician fixes the thumb of the first hand on the transverse process of the C3 vertebra on the side of the muscle block established during the diagnostic flexion test. The palm of the second hand is placed on the frontal-temporal region of the patient's head opposite the side of the established muscle block. Using the head as a lever, three successive maneuvers are performed: 1) first, the patient's head is passively turned towards the established muscle block until the patient's muscles begin to move under the thumb of the physician's first hand, which is installed on C3, 2) then passively extend the patient's head using the physician's hand until the patient's muscles begin to move under the thumb of the physician's first hand, 3) passively lateroflex the patient's head on the side of the established muscle block using the pressure of the physician's hands until the patient's muscles begin to move under the thumb of the physician's first hand, after which the movement is stopped, and the patient in this position performs 3 inhalation-exhalation cycles at a pace comfortable for him.

Then, in the reverse sequence of three movements, the patient's head is passively returned to the initial position and a repeated flexion test is performed, monitoring the dynamics of previously established muscle blocks at the level of the corresponding segments. If muscle blocks (MB) persist or recur, the therapeutic manipulation is repeated at the C2-C3 level until they are completely removed under the control of a diagnostic flexion test.

The accuracy of diagnostics of blocks at any levels of the spine and control of their removal and the state of biomechanics are achieved using this test in the process of therapeutic manual action, with the simplicity of its implementation and the possibility of rapid monitoring of the results of correction, improvement of blood flow in the vessels feeding the craniovertebral junction and other PDS, normalization of muscle tone and mobility in the PDS with the elimination of compression of the vascular-nerve bundles and dysfunction of the internal organs caused by FB at the corresponding levels; a stable therapeutic effect of at least six months. However, this method does not eliminate dysfunctions in the overlying AOS, which can also be associated with visual, auditory disorders, as well as with a number of disorders of the internal organs.

Another method of manual therapy of the cervical spine is known (RU 2803006 C1, 09/05/2023, Karev A.S., Chigarev A.A., Samorukov A.E., Yurova O.V., Fesyun A.D.), with the procedure of motor manipulations on the anatomical structures of the cervical spine in a certain sequence. Moreover, before performing each manipulation on the cervical spine and before each approach within the same manipulation, the doctor uses the pads of the first fingers to perform point kneading of the soft tissues of the neck in a circular motion down the paravertebral lines, descending from the level of the occipital tubercles to the level of C7, kneading is performed for 5 seconds at the level of each cervical vertebra. Manual therapy is performed every other day, 10 procedures. The method allows to quickly and technically simply eliminate the pain syndrome in the cervical spine with an increase in the volume of painless movements, a reduction in the recovery period of disability in all categories of patients, including patients with increased body weight, as well as with developed muscle mass, for example, athletes. Unlike the classical PIR, the patient does not need to strain the muscles in combination with any other action. However, the effects of the impact on the AOS (C0-C1) have not been described for this method either.

Craniosacral manual techniques are known that are used after a stroke (Sharapova I.N. et al. Craniosacral therapy in patients with ischemic stroke with hemiparesis. // Resort medicine. 2021, 3, pp. 120-125). At the first stage, symphysis compression is eliminated using the "shot from a gun" technique. At the second stage, the biomechanics of the sacrum is eliminated through a number of special manipulations. They normalize the tone and functions of a number of elements of the musculoskeletal system, including the position of the iliac bones, the base of the neck, the trapezius muscle, perform myofascial release in the area of its upper and horizontal portions, work with the craniocervical junction, eliminating the C1-C2 FB, performing flexion of the head and the cervical spine to an angle of 45 degrees, restore mobility in the AOS and correct extension dysfunction in it, eliminate pathobiomechanical changes in the sphenobasilar joint and connective tissue structures of the skull, etc. However, this known method is difficult to perform, requires the work of a highly qualified specialist in manual therapy, it cannot be simplified. Similar cranial manual therapy (through decompression and other techniques) is used for chronic cerebral ischemia, improving cerebrospinal fluid and hemodynamics, eliminating pathobiomechanical disorders in the cranial region, restoring the craniosacral rhythm, and promoting the full functioning of brain structures (RU 2457818 C1, 10.08.2012, N.V. Rogozhnikova et al.).

A method for treating vertebrobasilar insufficiency is also known (RU 2021799 C1, 10/30/1994), when the patient undergoes manual therapy on the area of the cervical spine joints in a lying position, performing maximum forward flexion of the head with simultaneous rotation to the side and performing repetitive rhythmic movements until the normal range of motion is restored, followed by straightening the head, maximum rotation to the side, placing it in a strictly sagittal and frontal plane, subsequent traction and rhythmic repetitive movements in the vertical plane until the normal range of motion is restored.

Known treatment methods allow achieving a therapeutic effect, in fact, only for the duration of the method’s use, and the effect may be far from complete.

There is a known relationship between cervicogenic headache, caused, among other things, by disorders at the C0-C1 level, and the blink reflex (Zagorulko O.I. et al. Methodological approaches to the treatment of pain syndromes of cervicocranial localization // Chronic pain syndromes. 2007, abstracts of reports, pp. 33-35; Matkhalikov R.A. et al. Blink reflex in unilateral headaches (migraine, cervicogenic headache, cluster headache) // Pain. 2007, 1(14), pp. 26-31), which can be used in developing a method for correcting dysfunction in the cervical spine, at the C0-C1 level.

There are known relationships between cervical spine disorders and various oculomotor disorders (Sitel A.B. et al. Pathogenesis of visual disorder syndrome in cerebral venous dysgemia in patients suffering from spondylogenic vertebrobasilar insufficiency // Manual therapy. 2010, 1(37), pp. 32-39), as well as the elimination of strabismus and other ophthalmological disorders by influencing the AOS (RU 2454984 C1, 10.07.2011, A.F. Belyaev et al.). The effectiveness of manual therapy of the cervical spine and the state of C0-C1 mobility are estimated based on the comparative sizes of blind spots on the retina (RU 2144778 C1, 27.01.2000, Bondarenko N.A. et al.).

Age-related changes in the cervical spine can have a significant impact on the hemodynamics of the eyes, their functional state and the rate of development of age-related diseases. In this regard, manual therapeutic effects are effectively performed in cases of visual impairment in cases of difficulty in venous outflow from the skull caused by chronic pathological spasm of the muscular corset of the neck in response to developing degenerative-dystrophic changes in the vertebrae, in the AOS. Visual impairment in this case can occur as a loss of visual fields (scotomas, homonymous hemianopsia, cortical blindness, less often - visual agnosia) or the appearance of photopsies. When the brain stem is damaged, there are disturbances in the functions of the cranial nerves - oculomotor disorders (diplopia, convergent or divergent strabismus, vertical misalignment of the eyeballs), peripheral paresis of the facial nerve, bulbar (less often - pseudobulbar) syndrome (Kamchatnov P.R. et al. Vertebrobasilar insufficiency - issues of diagnosis and treatment. Neurology - 2005 - Vol. 7. - No. 2, p. 18; Borisenko A.V. Differentiated use of manual therapy in patients with reflex syndromes of cervical osteochondrosis, author's abstract of diss... candidate of medical sciences 1992, 17 p.).

A method for treating ischemic eye diseases and postoperative eye conditions in presbyopic patients is known (RU 2612596 C1, 09.03.2017, M.G. Komarova et al.), in which a set of physical exercises in the cervical spine in a certain sequence is performed to treat eye diseases associated with impaired blood supply due to age-related changes in the cervical spine and after ophthalmological interventions. However, this method concerns independent exercise performance, which can lead to complications if performed incorrectly.

It should also be noted that the cause-and-effect relationships in the development of various pain syndromes associated with C0-C1 are known within the framework of the existence of myofascial chains (Bredikhin A.V. et al. Myofascial chains. The basis is myofascial dysfunctions, acupuncture and manual therapy in their correction. // Med. news. 2018, 10 (289), pp. 45-51; Orel A.M. Application of tense integrity models (tensegrity models) to describe the biomechanics of the spine. // Medical alphabet. 2010, vol. 1, no. 4, pp. 40-45).

A method for treating degenerative-dystrophic diseases of the cervical spine is known (RU 2147858 C1, 27.04.2000, Payukov I.I.), in which manual therapy techniques are used to eliminate functional blocks first in the lower cervical, then in the AAS and AOS under the control of the Q-T interval of the ECG. Manipulations are carried out only with unchanged, previously identified values of the Q-T ECG interval or its decrease, and mobilization when eliminating all functional blocks is carried out against the background of constant traction of the head with a force of 1.5-2 kg for 20-30 sec, and then intermittent with the same forces up to 10-15 sec, which prevents instability due to the preservation of the alar ligaments and allows dosing the effect. However, there is no data on the possibility of effectively using this method for chronic FB on C0-C1.

A method of atlas correction is known (RU 2794817 C1, 25.04.2023, Akhmetkhanov A.G. et al.), in which, after manual diagnostics, spasm of the AOS muscles is eliminated by means of vibration-point massage, which is performed symmetrically on the paired suboccipital muscles in a certain sequence. Improved blood supply to the upper part of the spinal cord, cerebellum and the back of the brain, improved blood flow through the vertebral arteries, achievement of correct paired symmetrical control of the suboccipital muscles, normalization of mobility in the AOS and AAS are achieved. However, this method requires the use of a special device and the work of a specialist who is proficient in the specified type of vibration-point massage.

A method for treating osteochondrosis of the cervical spine is known, which includes identifying hypertonicity of the neck muscles with subsequent elimination by applying pressure to the muscles in the sagittal plane, fixing the head and distracting the ligamentous-muscular apparatus of the neck (RU 2243758, 06.02.2003). In this case, the effect is produced on all the occipitovertebral muscles, as well as on the muscles located between the transverse processes of C1-C7 sequentially with forced turns of the head and traction. This can lead to an increase in the tone of the muscle group and an increase in the imbalance of muscle control. This method requires multiple repetitions and long-term complex therapy, it is not effective enough in terms of eliminating the difference in the tone of the paired suboccipital muscles. When diagnosing and selecting areas of impact, they are guided by the definition of muscle hypertonicity by detecting active, painful trigger points, but do not take into account the possibility of the presence of painless latent trigger points, asymmetry of the tone of the paired suboccipital muscles and the presence of FB C0-C1, C1-C2.

A method for treating discirculatory encephalopathy is known, in which, in addition to eliminating FB from the level of C2-C3 to C7-Th1, one of the stages is eliminating FB in the C0-C1 joint (RU 2430713 C2, 10.10.2011, Sitel A.B. et al.). In this known method, restoration of the normal range of motion of the vertebrae allows eliminating FB not only in the area of the upper cervical joints, but also in the mid-cervical and lower cervical spine and ensuring restoration of blood circulation both in the arteries of the vertebral-basilar basin and in the arteries of the internal carotid arteries basin. The method involves successive stages of mobilization and manipulation of the facet joints of the mid-cervical and lower cervical spine to eliminate PFL (persistent functional limitation of mobility), starting from the C2-C3 level and ending at the C7-Th1 level. Pain trigger zones are eliminated in the suboccipital region on the left and right sides by rhythmically and repeatedly pressing these pain trigger zones with the doctor's thumbs until the pain is completely eliminated and a feeling of relaxation of the tense and painful suboccipital muscles appears. PFL of the facet joints between C1 and C2 and in the AOS (C0-C1 joint) is eliminated. To do this, with the patient lying on his back, mobilizations and manipulations are performed on the AAS (C1-C2 joint) and AOS (C0-C1 joint). The thumb of the doctor's right hand fixes the transverse process of C2, the doctor uses his left hand to lateral tilt, flex and turn the patient's head to the left. Before manipulation on the C2-C3 joint, the doctor lateral tilts and extends the head, and before manipulation on the C1-C2 and C0-C1 joints, he lateral tilts and flexes the head. As a result of the manipulations performed, the relief of subjective and objective symptoms often occurs in patients after the very first procedure. In most patients, restoration of normal range of motion is achieved after 3-7, sometimes 8-10 procedures. Preferably, the procedures are performed once every two days.

However, the effectiveness of this known method for eliminating a number of underlying functional blocks, including the lumbosacral and sacroiliac PDS, has not been demonstrated.

This known method can be considered as the closest analogue (prototype) of the proposed invention.

The technical challenge is to develop a method of manual action on the cervical spine that would allow for the most complete removal of the underlying functional bulges of the spine.

The technical result of the proposed method is the detection of biomechanical disorders in the CVO due to a manual diagnostic procedure, improvement of the blood supply to the upper part of the spinal cord, cerebellum, posterior part of the brain, improvement of blood flow through the vertebral arteries due to the elimination of their irritation, normalization of mobility in the AOS and balancing of compensatory motor disorders in the PDS at lower levels.

To achieve the specified technical result, a method for correcting cervical spine dysfunction at the C0-C1 level is proposed by performing manual techniques on the atlantooccipital joint (AOS), in which the doctor first determines the range of motion in the joint at the C0-C1 level of the cervical spine,

To do this, the doctor places the bases of the index fingers on the transverse processes of the patient's C1 vertebra, fixing them, and then the doctor makes lateroflexion movements with the patient's head - tilting the head to the right and left.

If muscle tension is felt under the finger or fingers during movements to the right and left with a limitation of the volume of the corresponding direction of movement, the doctor determines the presence of a muscle block at the level of C1 and its side - right or left,

then the doctor passively tilts the patient's head with his hands towards the identified muscle block, fixing the transverse process of C1 on the side of the identified muscle block with the base of the corresponding index finger,

and the patient, in this position of the head, turns both eyeballs towards the identified muscle block in C1 to the maximum possible viewing angle, and, fixing the gaze, inhales and exhales 3 times in this position at a pace that is comfortable for him.

The patient then turns both eyeballs and fixes the gaze in the direction opposite to the identified muscle block in C1, to the maximum possible viewing angle, and inhales and exhales 3 times in this position at a pace that is comfortable for him,

then the patient returns the eyeballs to their normal middle position, and the doctor passively returns the patient's head to the middle position as well.

Repeat the passive tilt of the patient's head towards the identified muscle block in C1 and move his gaze 2 more times, then check the range of motion in the joint at the level of C0-C1 of the cervical spine, and if the muscle block is maintained, repeat all the described manipulations until the identified muscle block is removed within the framework of one procedure.

It is preferable that the physician performs the described manipulations of the method while standing behind the patient sitting astride a chair, or while sitting behind the head of the patient lying on his back.

Once again, we would like to emphasize that the proposed method is based on the principles of functioning of myofascial chains - a system of certain anatomical and functional muscular-fascial connections in the human body. When performing correction in the AOS, correction also occurs in the sacroiliac joint (SIJ), similar to the correction of the thoracic PDS when removing the FB at the level of C2-C3, as we have shown earlier, for example, in: RU 2823181 C1, 19.07.2024 (Samorukov A.E., Mikhalev V.S., Krivo Yu.A., Budylin S.P., Fesyun A.D.).

In addition, this method is based on the interactions of the craniocervical muscles, due to the presence of functional relationships between the movement of the eyeballs and the FB at the level of C0-C1. Thus, in the brain there is a single center for turning the head and eyes in one direction (precentral gyrus), coordinating both of these movements. Also, in particular, it has been reliably shown that with changes in the joints of the upper cervical spine (C0-C1-C2), their blocking is accompanied by visual and acoustic symptoms, dizziness, hypertonicity of the short suboccipital muscles and the development of myofascial trigger zones (MTZ) in the inferior oblique muscle of the head and the rectus capitis muscles on the homolateral side, as well as in the sternocleidomastoid muscle (Devlikamova F.I. et al. Cervicocranialgia: many causes, one problem. // RMJ, 2019, v. 27, no. 9, pp. 4-10).

Taking into account these known relationships, we propose:

1. When a C0-C1 block is detected, we tilt the patient's head to the same side of the detected FB until we feel a restriction and ask the patient to move his gaze to this side, fixing it and inhaling and exhaling 3 times at a pace that is comfortable for him.

2. The patient shifts his gaze to the opposite side from the blockade, fixing his gaze for 8-10 seconds, and during this time takes three deep breaths in and out at a comfortable pace, which allows for the removal of FB in C0-C1 and, accordingly, in the underlying segments with compensatory blockades associated with it by myofascial chains, including in the SIJ. Thus, the entire spine is balanced – from C0-C1 to the SIJ. This occurs due to the interaction of existing myofascial chains, the mutual influence of all their elements. Therefore, a generalized effect of muscle block removal can be achieved, in fact, in just one treatment procedure.

When the FB returns due to repeated loads, however, in the process of repeated manipulations on C0-C1, the entire spine is again balanced. In fact, the patient can do this simple manipulation even independently, actively, using not the base of the index finger (which is inconvenient when performed independently) to fix the transverse process of C1, but the thumb of the corresponding hand, and with the other hand helping to tilt the head towards the block. When the block returns, it is also possible to carry out repeated independent procedures, according to the formula of the invention.

In 2024-2025, 12 patients (5 men and 7 women, 30-68 years old) with a muscle block (MB) at the level of C0-C1 underwent manual correction using the proposed method; MB was established during manual examination. Additionally, manual diagnostics was performed to identify MB of the underlying segments. Blocks were detected in the mid-, lower-cervical and thoracic PDS (3 people), lumbosacral (4 people), and in the SIJ (5 people), with clinical manifestations corresponding to the localizations.

Cephalgic syndrome was observed in all patients (100%). There were complaints of pain in the occipital region, as well as in the parietal region, temple, and eye sockets. 75% of patients (9 people) had visual disturbances (reduced clarity of perception, ability to focus, darkening, feeling of fog in the eyes, appearance of flies, black dots before the eyes). In 50% (6 people), cochleovestibular manifestations with impaired coordination, unsteadiness while walking, dizziness - especially when turning the head were additionally detected. Noise or ringing in the ears was observed in 3 patients (25%).

For the purposes of the study, we used the VAS pain intensity assessment, which averaged 5-6 points (different patients experienced pain in the cervical spine, headaches, and pain along the thoracic, lumbar, and sacral segments of the spine), as well as the range of motion in the affected segments (reduced by 35-50% on average). According to X-ray data, all patients had signs of spinal osteochondrosis (5 people had cervicothoracic pain, the rest had signs of osteochondrosis in all sections).

All 12 patients underwent only manual intervention in accordance with the proposed method (according to the formula of the invention).

In one procedure, FB with the elimination of pathological symptoms and complaints was removed in 5 patients; during a control examination after 6 months, no return of the block was noted either in the cervical region or in the underlying regions.

In 3 patients, the described manipulations were repeated 2 times a week, after which the muscle blocks at all levels of the spine were also permanently removed.

In 4 patients, repeating the manipulations 2-3 times a week resulted in complete removal of FB, which, however, partially recurred and required repeated manipulations after 3 and 6 months. This could be associated with more pronounced initial manifestations of osteochondrosis in older patients.

In general, after 6 months, positive results were noted in all patients: pain syndrome according to VAS 1-2 points (improvement by 3-4 points compared to the initial value), increase in the range of motion in the affected segments by an average of 20-25%.

The comparison group consisted of 10 patients who received physiotherapy (magnetic laser therapy, electrophoresis with a muscle relaxant), and corresponding exercise therapy complexes due to the presence of muscle blocks of C0-C1 and lower segments and osteochondrosis. Improvement was observed, a decrease in the pain level according to VAS by 1-2 points, an increase in the range of motion in the affected segments by 10-15% compared to the initial level.

However, after 3-4 months, 8 patients returned for treatment due to partial resumption of pain syndrome and decreased range of motion.

A statistical study was not conducted due to the small sample size, however, the obtained factual data indicate the effectiveness of the proposed method, including the removal of FB during manipulations on C0-C1 not only in the cervical spine, but also in the lower parts of the spine, and the possibility of maintaining them for a fairly long time - 3-6 months, without requiring any additional therapeutic interventions.

Clinical examples

1. Patient D., 35 years old. Complaints of almost constant pain in the occipital region of the neck radiating to the head, in the thoracolumbar spine, attacks of causeless rapid heartbeat, shortness of breath; at times - weakness, fatigue, decreased ability to concentrate, "flies" before the eyes, dizziness. When walking after sitting for a long time, there are initial difficulties in moving the legs forward. The patient has been noticing complaints for the past 6-8 months, has a sedentary job. The somatic anamnesis is not burdened.

According to the ultrasound Doppler of the head and neck vessels, there is a decrease in the blood flow velocity in the vertebral arteries, cerebellar arteries, upper part of the spinal cord, back of the brain, on the right - more pronounced than on the left. According to the radiography data - signs of initial osteochondrosis in the cervical, thoracic and lumbar spine.

During examination, the intensity of the pain syndrome was 5 points according to VAS, movement limitation in the cervical spine (flexion-extension and side bends). During testing according to the proposed method, a muscle block was detected at the level of C0-C1 on the right. Blocks were also detected at the levels of C2-C3, Th7-9, L1-4 and in the sacroiliac joint. Tension of the suboccipital muscles, neck extensors, and long back muscles was expressed.

The patient underwent the manipulation procedure on an outpatient basis, in accordance with the invention formula, with the patient sitting astride a chair.

The muscle block on the right in C0-C1 was removed during a single procedure, without requiring repetition. Upon completion, the pain syndrome according to VAS was 0 points, there was no limitation of movement. No FBs were detected during examination of the underlying segments (including at the level of the SIJ).

According to the control ultrasound Doppler examination of the vessels of the head and neck, the blood flow velocity in the arteries concerned has normalized.

After 3 and 6 months, during follow-up examinations, the patient has no complaints, the result is stable.

2. Patient M., 58 years old. Complaints of dizziness, pain when moving the eyeballs, sometimes unsteadiness when walking, a feeling of numbness in the hands, with emotional stress, an increase in blood pressure to 160/90 mm Hg. - diffuse bursting headache, occasionally - panic attacks. Concomitant diseases: coronary heart disease stage 1, hypertension stage 1, osteochondrosis of the cervicothoracic spine, osteoarthrosis stage 1, instability of the sacroiliac joint.

Manual diagnostics revealed increased tone of the postural extensor muscles of the neck and long extensors of the back. Pain syndrome is sharply expressed upon palpation of the compacted left anterior scalene muscle, muscles of the shoulder girdle and neck, more on the left. There are muscle blocks in C0-C1 (left), C7-Th1 (left), sacroiliac joint (left). Pain syndrome according to VAS is 6 points, limitation of movement in C0-C1, in the sacroiliac joint.

The patient underwent a manual procedure in accordance with the formula of the proposed invention (with the patient lying down, due to dizziness). The identified muscle blocks were eliminated only after its threefold repetition. Pain according to VAS - 2 points, no limitation of movement.

After 3 months, a relapse was observed – the muscle blocks “returned”.

The procedure was repeated 3 times a week (i.e. 3 more procedures were performed), after which the muscle blocks at all identified levels were again relieved.

After another 3 months, there are no relapses.

Thus, the proposed method is effective for various FB muscles at different levels of the spine, allowing to obtain a lasting positive effect both in terms of pain relief and in terms of normalizing the range of motion, has virtually no contraindications, is easy to perform with appropriate simple training, and allows it to be performed even by the patient independently.

Claims (10)

1. A method for correcting dysfunction of the cervical spine (CS) at the level of C0-C1 by performing manual techniques on the atlantooccipital joint (AOS), characterized by the fact that the doctor first determines the range of motion in the joint at the level of C0-C1 of the cervical spine, to do this, the doctor places the bases of the index fingers on the transverse processes of the patient's C1 vertebra, fixing them, and then the doctor makes lateroflexion movements with the patient's head - tilting the head to the right and left, if there is a feeling of muscle tension under the finger or fingers during movements to the right and left with a limitation of the volume of the corresponding direction of movement, the doctor ascertains the presence of a muscle block at the level of C1 and its side - right or left, then the doctor passively tilts the patient's head with his hands towards the identified muscle block, fixing the transverse process of C1 on the side of the identified muscle block with the base of the corresponding index finger, and the patient, in this position of the head, turns both eyeballs towards the identified muscle block in C1 to the maximum possible viewing angle and, fixing the gaze, inhales and exhales 3 times in this position at a pace that is comfortable for him, then the patient turns both eyeballs and fixes the gaze in the direction opposite to the identified muscle block in C1, to the maximum possible viewing angle, and inhales and exhales 3 times in this position at a pace that is comfortable for him, then the patient returns the eyeballs to the normal middle position, the doctor passively returns the patient's head also to the middle position; repeat the passive tilt of the patient's head towards the identified muscle block in C1 and the movement of his gaze 2 more times, then check the range of motion in the joint at the level of C0-C1 of the cervical spine, and if the muscle block is maintained, repeat all the described manipulations until the identified muscle block is removed within the framework of one procedure. 2. The method according to item 1, characterized in that the doctor carries out the manipulations of the method while standing behind the patient sitting astride a chair, or while sitting behind the head of the patient lying on his back.