Manual therapy:

20 minute/session, 2 sessions/week for 5 weeks.

Osteopathic based mobilization from a supine position the mobilization was preformed 3 times in each of the following directions.

  1. Translation upward: The head and the upper cervical spine were lifted up by pushing the spinous processes with both hands to apply the force to the movement
  2. Translation sideways: The cervical vertebra was pushed alternately toward the right and the left sides by the force applied to each facet joint. The hands tightly supported each side of the head and the upper cervical column, which were moved directly sideways at each treated level.
  3. Side bending: The cervical spine was bent alternately to each side. The hands supported along each side of the head and the cervical column with the pads of the fingertips over the mobilized facet joint. The head and the cervical column were bent to each side, and the fingertips were then moved upward over the next facet joint.
  4. Rotation and side bending in the same direction: The head was supported by the therapist’s lower mid-abdomen and the hands supported the head and the upper cervical spine. The hands overlaid each other, forming a bridge so that the heads of the metacarpal bones were over the facet joints. Prior to mobilization, the cervical column was moved sideways and rotated in the same direction to about half of total range of movement. The movement was then continued so that connective tissues became stretched without causing pain. The head and the neck were returned after each movement to their starting position. The head was rotated to the other side for the same treatment.
  5. Rotation with small range of movement: The pads of the tips of the middle and the ring fingers were placed over the spinous processes and then the fingers were straightened so that the middle phalanxes of the fingers were over the facet joint. The head was supported with the hand on the opposite side, allowing the movement to happen, and then the head returned to the middle position. The other side was treated by moving to the opposite side of the treatment table.
  6. Mobilization of upper cervical joints: Both hands supported the occiput with the tips of the middle and the ring fingers over the arch of the atlas on each side. The head was bent sideways slightly and turned in the opposite direction, causing the atlas to move against the fingertips.


3 repetitions, 30 second hold, 5 times/week for 5 weeks.

  1. Stretching toward lateral flexion for the upper part of the trapezius: the chest was put up and kept on the chair with one hand. The head was turned toward the hand that was kept on the chair. The free hand was used to pull the head straight toward the opposite side. To feel more stretched, the body was slightly leaned away from the hand that was being kept on the chair to depress the shoulder further.
  2. Ipsilateral flexion and rotation for the scalene: The chest was put up forward on the edge of the chair. The leg or the seat of the chair was tightly held with 1 hand to keep the ribs down. The head was side flexed to the opposite side without flexing the head forward. The patients often found themselves more stretched if they rotated their heads slightly toward the hand holding on the chair and slightly extended the neck side flexing.
  3. Flexion for the extensor muscles: The patient put his chest up and looked straight ahead. He gently pushed his chin back while looking straight ahead (so that he had a double chin). Then he kept his head upright, not looking up or down. The eyes were kept facing forward. While holding the chin back with one hand, the other hand was used to reach over the top of the head. He was to stabilize his chin back while gently pulling the top of the head forward.
  4. Levator scapula stretch: The right hand was put up over the shoulder and the elbow was brought back pointing up to the ceiling. The left hand was used to pull the head forward and to the left.
  5. Neck-straightening exercise: First, the head was retracted by tucking in the chin. While keeping the chin tucked in, the head was tilted back. The patients could assist themselves with their hands for more comfort.