Chapter 25. The Cervical Spine

At the completion of this chapter, the reader will be able to:

1. Describe the anatomy of the vertebrae, ligaments, muscles, and blood and nerve supply that comprise the cervical intervertebral segment.

2. Describe the biomechanics of the cervical spine, including coupled movements, normal and abnormal joint barriers, kinesiology, and reactions to various stresses.

3. Perform a detailed objective examination of the cervical musculoskeletal system, including palpation of the articular and soft tissue structures, specific passive mobility tests, passive articular mobility tests, and stability tests.

4. Perform and interpret the results from combined motion testing.

5. Assess the static and dynamic postures of the cervical spine and implement the appropriate intervention.

6. Apply manual therapy techniques using the correct grade, intensity, direction, and duration.

7. Evaluate intervention effectiveness in order to progress or modify the intervention.

8. Plan an effective home program, including spinal care, and instruct the patient in this program.

9. Help the patient to develop self-reliant intervention strategies.

The cervical spine, (Fig. 25-1) which consists of 37 joints, permits more motion than any other region of the spine. The majority of the anatomy of the cervical spine can be explained in reference to the functions that the head and neck perform on a daily basis. To carry out these various tasks, the head has to be provided with the ability to perform extensive, detailed, and, at times, very quick motions. These motions allow for precise positioning of the eyes and the ability to respond to a host of postural changes that result from stimulation of the vestibular system (see Chap. 3).1 In addition to providing this amount of mobility, the cervical spine has to afford some protection to several vital structures, including the spinal cord and the vertebral and carotid arteries. However, with stability being sacrificed for mobility, the cervical spine is rendered more vulnerable to both direct and indirect trauma.2 Neck and upper extremity pain are common in the general population, with surveys finding the 1-year prevalence rate for neck and shoulder pain to be 16–18%.2,3 This frequency is also reflected in the prevalence of neck pain in the outpatient physical therapy setting, which has been found to be between 15% and 34%.3,4 In the younger population, cervical pathology is most commonly due to a ligament sprain or muscle strain, whereas in the older population cervical injuries are more commonly due to cervical spondylosis and/or spinal stenosis. Due to the complexity of this area, sufficient time must be allowed for a comprehensive examination to ensure that all causes of the signs and symptoms are determined.

Bogduk and Mercer5 divide the cervical spine into four anatomical units: the atlas, the axis, the C2–3 junction, and the remaining cervical vertebrae. For the sake of simplicity, these units are described in separate chapters. The atlas, axis, and C2–3 junction are described in Chapter 23. The remaining cervical vertebrae are described in this chapter.

Vertebrae

Compared with the rest of the spine, the vertebral bodies of the cervical spine are small and consist predominantly of trabecular (cancellous) bone.1 The third to sixth cervical vertebrae can be considered typical, whereas the seventh is atypical. The third, fourth, and fifth vertebrae are almost identical, whereas the sixth has enough minor differences to distinguish it from the others.

The typical cervical vertebra has a larger transverse than anteroposterior dimension. The superior aspect of the centrum is concave transversely and convex anteroposteriorly, forming a sellar surface that reciprocates with the inferior surface of the centrum, superior to it.1 The superior surface of the vertebral body is characterized by superiorly projecting processes on their superolateral aspects. Each of these hook-shaped processes is called an uncinate process and is composed of the raised lip of the superolateral aspect of the body, which articulates with a reciprocally curved surface at the synovial uncovertebral joint.

Variations in the lower cervical vertebrae are most commonly found in the spinous and transverse processes. The transverse processes are short and project anterolaterally and slightly inferiorly and are typified by a foramen in each. The transverse processes of vertebrae C3–6 are posterior and lateral to the transverse foramina, through which the vertebral artery, accessory vertebral vein, and the vertebral nerve all pass.

With the exception of the C2 vertebra (see Chap. 23), the superior aspect of the transverse process has a deep groove that mimics the orientation of the transverse process and the spinal nerve, both of which are parallel with the intervertebral foramen. The inferolateral orientation of the transverse process, and the fact that the spinal nerves are firmly anchored in the groove, makes the nerves vulnerable to a stretch injury around the distal end of the transverse process.1

The articular pillars and zygapophyseal (facet) joints of vertebrae C2–7 are located approximately 1 inch lateral to the spinous processes. The articular pillar is formed by the superior and inferior articular processes of the zygapophyseal joint, which bulge laterally at the pedicle–lamina junction. The articular facets on the superior articular process are concave and face superolaterally to articulate with the reciprocally curved and orientated facet on the inferior articular process of the vertebra above. The articular pillars bear a significant proportion of axial loading.6

As in the rest of the spine, the pedicles and laminae form the neural arch, which encloses the vertebral foramen. The pedicles project backward and laterally, whereas the long, narrow laminae run posteriorly and medially, to terminate in a short bifid spinous process, which projects slightly inferiorly.1 The seventh cervical vertebra varies from the typical cervical vertebra. In addition to possessing a much longer and monoid spinous process to which the ligamentum nuchae attaches, the seventh vertebra has wider transverse processes, no inferior uncinate facet, and no transverse foramen.

Intervertebral Disk

In the cervical spine, there are five disks, with the first disk being located between C2 and C3. The cervical disks (Fig. 25-2) are named after the vertebra above (C4 disk lies between C4 and C5). The anatomy of the cervical disk is distinctly different from that of the lumbar intervertebral disk (IVD). The cervical nucleus pulposus (NP) at birth constitutes no more than 25% of the entire disk, not 50% as in lumbar disks.7

The IVD height-to-vertebral body height ratio (2:5) is the greatest in the cervical spine, and the IVDs make up approximately 25% of the superior-to-inferior height of the cervical spine.8 This increase in height ratio allows for the greatest possible range of motion. The NP sits in, or near, the center of the disk, lying slightly more posteriorly than anteriorly. The inferior surface of the cervical IVD is concave, and the inferior–anterior surface of the centrum projects downward to partly cover the anterior aspect. The anterior margin of the IVD is attached to the anterior longitudinal ligament (ALL). This surface can be palpated by the clinician and is often tender in the presence of intervertebral instability. The diskal margins of the posterior surface of the vertebral body give rise to the posterior longitudinal ligament (PLL).

A number of features distinguish the cervical disk from the lumbar disk9:

• Anteriorly, the cervical annulus fibrosis (AF) consists of interwoven alar fibers, whereas posteriorly, the AF lacks any oblique fibers and consists exclusively of vertically orientated fibers.
• Essentially, the cervical AF has the structure of a dense anterior interosseous ligament, with few fibers to contain the NP posteriorly.
• In no region of the cervical AF do successive lamellae exhibit alternating orientations. In fact, only in the anterior portion of the AF—where obliquely orientated fibers, upward and medially, interweave with one another—does a cruciate pattern occur.
• Posterolaterally, the NP is contained only by the alar fibers of the PLL, under or through which the nuclear material must pass if it is to herniate. Further protection against disk herniation is afforded by the uncovertebral joints, which reinforce the posterolateral aspect of the IVD.
• The absence of an AF over the uncovertebral region. In this region, collagen fibers are torn during the first 7–15 years of life, leaving clefts that progressively extend across the back of the disk. Rather than an incidental age change, this disruption has been interpreted either as enabling10 or resulting from11 rotatory movements of the cervical vertebrae (see next section).
• Axial rotation of a typical cervical vertebra occurs around an oblique axis perpendicular to the plane of its facets.11

As in the rest of the spine, the cervical IVD functions as a closed but dynamic system, distributing the changes in pressure equally to all components of the container (i.e., the end plates and the AF) and across the surface of the vertebral body. It has been observed that in the first and second decades of life, before complete ossification occurs, lateral tears occur in the AF, most probably induced by motion of the cervical spine in the bipedal posture.12 The tears in the lateral part of the disk tend to enlarge toward the medial aspect of the IVD. The development of such tears through both sides may result in a complete transverse splitting of the disk. Such a process can be observed in the second and third decades of life in the lower cervical spine when the IVD is split in the middle into equal halves.12 With this aging process, the NP rapidly undergoes fibrosis such that, by the third decade, it is fibrocartilaginous in nature.13 Almost everyone older than 40 years of age has evidence of cervical disk degeneration.14 According to Töndury and Theiler,15 in the fourth and fifth decades of life, the NP usually dries out, and acute extrusion is not expected then. This development can be visualized on conventional radiographs as a flattening of the uncovertebral processes and a narrowing of the IVD space.16 This may lead to a loss of elasticity and increased stresses on the vertebral end plates.

These age-related changes are evident chemically and morphologically and are much more evident in the NP than in the AF. Degenerative disk disease in this region results in diminished disk height, subjecting the bony elements to increased load.8 The splitting of the IVD in the second and third decades of life may result in segmental instability.12 Also, such splitting of the IVD can allow the NP to move toward the spinal canal, ultimately causing disk protrusion or extrusion and resulting in nerve root compression.12

In general, compression of the cervical nerve roots occurs at the entrance zone of the intervertebral foramina.17 Anteriorly, compression of the nerve roots is likely caused by protruding disks and osteophytes of the uncovertebral region, whereas the superior articular process, the ligamentum flavum, and the periradicular fibrous tissues often affect the nerve posteriorly.17–20 Osteophytes develop in response to this increased stress and from degenerative changes of the zygapophyseal and uncovertebral joints. The osteophytes effectively increase the available surface area and decrease the overall force on the end plates.21 Radicular arteries within the dural root sleeves may become compressed by osteophytes, leading to spasm and decreased vascular perfusion.21 In addition, venous obstruction may occur, resulting in edema and additional reduction in nerve root perfusion.21

The nerve root is divided into the anterior (ventral) and posterior (dorsal) roots (Fig. 25-2), which are responsible for motor and sensory functions, respectively. Ebraheim and colleagues22 described the quantitative anatomy of the cervical nerve root groove and divided it into three zones: medial zone (pedicle), middle zone (vertebral artery foramen), and lateral zone. The medial zone of the cervical nerve root groove corresponds to the intervertebral foramen, and this zone is believed to play an important role in the etiology of cervical radiculopathy.17 The intervertebral foramen, which can be further divided into an entrance zone (medial) and an exit zone (lateral), resembles a funnel in shape. The entrance zone corresponds to the narrow part of the funnel, and the shape of the radicular sheath is conical, with its takeoff points from the central dural sac being the largest part.17 Consequently, nerve root compression occurs mostly in the entrance zone of the intervertebral foramina. Whether compression of the anterior (ventral) roots, posterior (dorsal) roots, or both occurs depends on various anatomic structures around the nerve roots. Anteriorly, compression of the nerve roots is likely caused by protruding disks and osteophytes of the uncovertebral region, whereas the superior articular process, the ligamentum flavum, and the periradicular fibrous tissues often affect the nerve posteriorly.17–20 Osteophytes may develop in response to this increased stress and form degenerative changes of the zygapophyseal and uncovertebral joints. The osteophytes effectively increase the available surface area and decrease the overall force on the end plates.21 Radicular arteries within the dural root sleeves may become compressed by osteophytes, leading to spasm and decreased vascular perfusion.21 In addition, venous obstruction may occur, resulting in edema and additional reduction in nerve root perfusion.21

Articulations

The structure of the cervical vertebrae, combined with the orientation of the zygapophyseal facets, provides very little bony stability, and the lax soft tissue restraints permit large excursions of motion.1 A narrow space exists between the spinal cord and the vertebral canal walls in this region. There also is a very small amount of extra space in the intervertebral foramina. Thus, a relatively small change to either the vertebral canal or the dimensions of the intervertebral foramen can result in significant compression of the spinal cord or the spinal nerve, respectively.23

Each pair of vertebrae in this region is connected by a number of articulations: a pair of zygapophyseal joints, two uncovertebral joints, and the IVD.

Zygapophyseal Joints

There are 14 zygapophyseal joints (Fig. 25-2) from the occiput to the first thoracic vertebra (C1–7). These joints are typical synovial joints and are covered with hyaline cartilage. The articular facets are teardrop shaped, with the superior facet facing up and posteriorly, while the inferior one faces down and anteriorly. In the middle to lower cervical regions, the dual requirements of stability and mobility are provisioned through zygapophyseal joints, with C5–6 contributing the greatest segmental mobility. The average horizontal angle of the joint planes of the middle segments is approximately 45 degrees between the frontal and transverse planes24,25 with the upper cervical levels being closer to 35 degrees, and the lower levels at approximately 65 degrees.

The orientation of the zygapophyseal joint planes in the midcervical spine permits considerable flexibility in the motions of flexion and extension and encourages the coupling motions of rotation and side bending to the same side in the upper segments (see Chap. 22). However, the more caudal segments approaching the cervicothoracic junction show a tendency for a smaller range of motion—it is here that axial loading is higher and the segmental mobility becomes markedly diminished as the thoracic cage commences.26

The anterior joint capsule is strong, but it is lax in neutral and extension.27 The posterior capsule is thin and weak. This laxity allows for translation between facets. The major constraints and supports of these joints are the ligaments of the vertebral column and the IVD.

Vascular, fat-filled, synovial intra-articular inclusions5 have been observed in these joints. These structures have been described as fibroadipose meniscoids, synovial folds, and capsular rims. The meniscoids consist of connective and fatty tissue that is highly vascularized and innervated.12 In the cervical spine, the meniscoids function as space fillers for the uneven articular surfaces, especially in regions where the elasticity of the relatively thin cartilage is not sufficient.12 These inclusions, which are theorized to play some role in protecting the articular surfaces as they are sucked in or expelled during movements, are prone to entrapment and can play a potential role in intra-articular fibrosis and cervical spine pain.28 Töndury and Theiler15 have observed that the meniscoids atrophy and virtually disappear with increasing age.

The zygapophyseal joint receives its nerve supply from the medial branches of the cervical posterior rami from C2 to C8 and the recurrent meningeal (sinuvertebral) nerve. The recurrent meningeal (sinuvertebral) nerve also innervates the anterior dural sac, the posterior AF, and the PLL. The capsular pattern of the zygapophyseal joint is a limitation of extension and equal loss of rotation and side bending, with flexion being unaffected.

Uncovertebral Joints

From C3 to T1, there usually are a total of 10 saddle-shaped, diarthrodial articulations. These articulations, known as joints of Luschka, uncinate processes, or uncovertebral joints, are formed between the uncinate process found on the lateral aspect of the superior surface of the inferior vertebra and the beveled inferolateral aspect of the superior vertebra.29 The uncovertebral joints develop within the first 12 years of life, as a result of loading from the head, and become fully developed by about 33 years of age.30,31 Two of these uncovertebral joints are found between each pair of adjacent vertebrae in the cervical spine proper (C2–3 to C6–7). The uncovertebral joint maintains a synovial compartment and creates the posterior lateral border of the IVD.32

The biomechanical role of the uncovertebral joint is thought to be that of a sagittally oriented guiding rail during cervical flexion and extension that acts to transfer rotation forces into side bending and posterior translation motions.29,33,34 This function is accomplished while simultaneously ensuring that the translation and, to some extent, the side bending (lateral flexion) between adjacent vertebral bodies are limited to the sagittal plane.29,33,34 This stabilizing feature develops and changes with age and is based on alterations in the uncinate processes.35

Penning and Wilmink37 highlighted a possible correlation between uncovertebral joint configuration and the coupled cervical segmental motion of side bending and axial rotation. A more recent study of the C5–6 segment level by Clausen and colleagues38 found that both the zygapophyseal joints and the uncovertebral joints are the major contributors to coupled motion in the lower cervical spine and that the uncinate processes effectively reduce motion coupling and primary cervical motion (motion in the same direction as load application), especially in response to axial rotation and side-bending loads. 38

The onset of degenerative changes in the cervical spine has been shown to occur more commonly at the midcervical level than at the lower cervical level.39 The reasons for the different degrees of involvement are not clear. The degenerative changes result in the substitution of a hinge-like motion, with the pivot point on the contralateral side, in place of the normal gliding motion at the uncovertebral joints.1 This alteration effectively transforms the cervical segment into a sellar joint.15,37,40

The nerve roots in the midcervical level are more predisposed to osteophytic compression because of a combination of

• higher uncinate process;
• smaller anteroposterior diameter of the intervertebral foramina;
• longer course of nerve roots in close proximity to the uncovertebral joints at C4–6 levels;
• greatest segmental mobility at C5 and C6.

The vertebral artery may also be compromised in the degenerative cervical spondylotic process. When involved, the vertebral artery (see Chap. 24) usually is compromised at the level of the inferior aspect of the superior vertebra, where the apical posterolateral uncovertebral osteophytes are present.

Intervertebral Foramina

The intervertebral foramina are found between all vertebrae of the spine, except in the upper cervical spine. Although there are seven cervical vertebrae, there are eight intervertebral foramina. This difference occurs because there is a nerve root existing between the occiput and the atlas (C1) that is designated to the C1 nerve root. The cervical intervertebral foramina are 4–5 mm long and 8–9 mm high. They extend obliquely anteriorly and inferiorly from the spinal canal at an angle of 45 degrees in the coronal plane.41 The anterior boundary of the foramen is formed by the IVD and by portions of both vertebral bodies, with the zygapophyseal joints serving as the posterior boundaries. The pedicles form the superior and inferior boundaries. The medial to lateral depth of the posterior wall is formed by the lateral aspect of the ligamentum flavum.

The intervertebral foramina serve as the principal routes of entry and exit for the neurovascular systems to and from the vertebral canal. Within each foramen are

• a segmental mixed spinal nerve;
• from two to four recurrent meningeal nerves or sinuvertebral nerves;
• various spinal arteries;
• plexiform venous connections.

Because they contribute to the innervation of the upper limb, the lower cervical spinal nerves are quite large in diameter and nearly fill the foramina. This region is vulnerable to narrowing with certain motions, or with osteophyte growth. The dimensions of the intervertebral foramina decrease with full extension and ipsilateral side bending of the cervical spine such that uncovertebral osteophytes may compress the nerve root and cervical cord posteriorly.

The spinal nerves also are in close proximity to both the ligamentum flavum and the zygapophyseal joint. Thus, zygapophyseal joint arthritis or a hypertrophic ligamentum flavum can cause posterior impingement of these nerves.

Vertebral Canal

In the cervical region, the vertebral canal contains the entire cervical part of the spinal cord, as well as the upper part of the first thoracic spinal cord segment. There are eight cervical spinal cord segments, and thus eight cervical spinal nerves (see Chap. 3) on each side, but only seven cervical vertebrae.

Ligaments

Both the function and the location of the ligaments in this region are similar to that of the rest of the spine. For the purposes of these descriptions, the short ligaments that interconnect the adjacent vertebrae are classified as segmental, whereas those that attach to the peripheral aspects of all of the vertebrae are classified as continuous.

Continuous Ligaments

Anterior Longitudinal Ligament

The ALL (Fig. 25-1) is a strong band, extending along the anterior surfaces of the vertebral bodies and IVDs, from the front of the sacrum to the anterior aspect of C2. The ALL is narrower in the upper cervical spine but is wider in the lower cervical spine than it is in the thoracic region. It is firmly attached to the superior and inferior end plates of the cervical vertebrae, but not to the cervical disks. At the waist of the centrum, the ligament thickens to fill in the concavity of the body. The ALL functions to restrict spinal extension and is thus vulnerable to hyperextension trauma.

Posterior Longitudinal Ligament

Lying on the anterior aspect of the vertebral canal, the PLL extends from the sacrum to the body of the axis (C2), where it is continuous with the tectorial membrane (Fig. 25-1). The PLL travels over the posterior aspect of the centrum, attaching to the superior and inferior margins of the body, but is separated from the waist of the body by a fat pad and the basivertebral veins. In addition, this ligament attaches firmly to the posterior aspect of the IVDs, laminae of hyaline cartilage, and adjacent margins of vertebral bodies. The PLL is broader and considerably thicker in the cervical region than in the thoracic and lumbar regions.42 The PLL functions to prevent disk protrusions and also acts as a restraint to segmental flexion of the vertebral column.

The dura mater is strongly adherent to the PLL at the level of C3 and higher, but this attachment diminishes at lower levels.

Ligamentum Nuchae (Nuchal Ligament)

This bilaminar fibroelastic intermuscular septum spans the entire cervical spine, extending from the external occipital protuberance to the spinous process of the seventh cervical vertebra.43 Some consider the ligament to be an extension or a replacement of the supraspinous and interspinous ligaments.44,45 However, an observational study by Allia and Gorniak46 suggest that it is a distinct ligamentous structure comprised of four portions formed by aponeurotic fibers from the trapezius, splenius capitis, rhomboid minor, and the serratus posterior superior.45 The ligament is described as being a strong, thick band of elastic tissue that aids in the suspension of the head, neck.45 However, the function of the nuchal ligament is controversial. While Mercer47 suggests that the only contribution of the ligament to stability is at C7 and the occiput, others have proposed that the ligament may play a more important role in cervical stability,46,48 while still others have proposed that it many play a role in posterior dural stretching and cervicogenic headaches. Studies45–47 have shown that when the occipitoatlantal joint is flexed, the superficial fibers of the ligament tighten and pull on the deep laminae and muscular attachments, which, in turn, pull the vertebrae posteriorly, limiting the anterior translation of flexion and, therefore, flexion itself.

Segmental Ligaments

The interspinous ligaments are thin and almost membranous, interconnecting the spinous processes. The ligament is poorly developed in the upper cervical spine but well developed in the lower.42

The ligamentum flavum runs perpendicularly to the spine from C1 and C2, where it is referred to as the posterior atlantoaxial ligament, to L5 and S1. This ligament connects the laminae of successive vertebrae, from the zygapophyseal joint to the root of the spinous process. It is formed by collagen and yellow elastic tissue and, therefore, differs from all other ligaments of the cervical spine. The ligamentum flavum of the cervical spine is fairly long, allowing an appreciable amount of flexion to occur, while maintaining tension when the head and neck are in neutral. Scarring or fatty infiltration to the ligament in this region can compromise the degree of elasticity, making the ligament lax, particularly with cervical extension. This laxity increases the potential for the contents of the vertebral canal to be compressed by the buckling ligament.49 Any enlargement of the ligament increases the likelihood that a spinal nerve or its posterior root will become impinged.9 The ligament appears to function as a restrictor of flexion of the neck.

Muscles

The neck muscles are characteristically grouped in layers50:

• The superficial layer consists of muscles that connect the skull and shoulder girdle and include the trapezius (Fig. 25-3) and sternocleidomastoid (SCM) (Fig. 25-3). Other superficial muscles, which connect the scapula with the vertebral column, include the levator scapulae and the rhomboids. The scalene muscle group (Fig. 25-4) provides a relationship between the cervical spine and the first and second ribs.
• A deeper layer links the skull and vertebral column and includes long posterior (dorsal) (splenius capitis (Fig. 25-5), semispinalis capitis, and longissimus capitis).
• The deepest layers consist of muscles that link the cervical and thoracic vertebrae, splenius cervicis, semispinalis cervicis, and longissimus cervicis.

For the most part, the muscles of the neck function to support and move the head. Given the number of degrees of freedom available at the neck, it is likely that the muscles are organized as functional synergies. Muscle synergies are conceptualized as units of control, incorporating the muscles around the joint that will act together in a functional fashion.50 Under this concept, the central nervous system (CNS) needs only trigger a synergic unit to produce a specific movement, instead of communicating with each individual muscle.50 Synergistic movements incorporate both agonist and antagonist muscle groups, which results in a greater level of control.

Superficial Muscles

Trapezius

The trapezius muscle (Fig. 25-3) is the most superficial back muscle. It is a flat triangular muscle that runs from the superior nuchal line and external occipital protuberance of the occipital bone to the spinous process of T12 and is the largest muscle attachment in the body. Its insertion can be traced from the entire superior aspect of the spine of the scapula, the medial aspect of the acromion, and the posterior aspect of the lateral third of the clavicle.

This muscle traditionally is divided into middle, upper, and lower parts, according to anatomy and function.

• The middle part originates from C7 and forms the cervicothoracic part of the muscle.
• The lower part, attaching to the apex of the scapular spine, is relatively thin.
• The upper part (Table 25-1) is very thin, and yet it has the most mechanical and clinical importance to the cervical spine.51

The innervation for the trapezius comes from the accessory nerve (CN XI) and fibers from the anterior (ventral) rami of the third and fourth cervical spinal nerves, with the former being speculated to provide the motor innervation and the latter supplying the sensory information.52–56 The greater occipital nerve occasionally travels through the trapezius near its superior border to reach the scalp and can become entrapped by an adaptive shortening of the upper trapezius muscle or be traumatized by a blunt force.56–58

The different parts of this muscle provide a variety of actions on the shoulder girdle, including elevation and retraction of the scapula. When the shoulder girdle is fixed, the trapezius can produce ipsilateral side bending and contralateral rotation of the head and neck. Working together, the trapezius muscles can produce symmetric extension of the neck and head.59 In addition, the trapezius muscle can produce scapular adduction (all three parts), and upward rotation of the scapula (primarily the superior and inferior parts). The importance of the trapezius to the shoulder joint is discussed in Chapter 16.

Sternocleidomastoid

The SCM (Fig. 25-3) is a fusiform muscle that descends obliquely across the side of the neck, forming a distinct landmark for palpatory purposes. It is the largest muscle in the anterior neck. It is attached inferiorly by two heads, arising from the posterior aspect of the medial third of the clavicle and the manubrium of the sternum. From here, it passes superiorly and posteriorly to attach on the mastoid process of the temporal bone. The motor supply for this muscle is from the accessory nerve (CN XI), whereas the sensory innervation is supplied from the anterior (ventral) rami of C2 and C3.60 This muscle can provide the clinician with information regarding the severity of symptoms, and postural impairments, because of its tendency to become prominent when hypertonic. The SCM also is involved with a condition called torticollis, a postural deformity of the neck (see Chap. 5 and later).

In broad terms, the actions of this muscle are flexion, side bending, and contralateral rotation of the head and neck.59 Acting together, the two muscles draw the head forward and can also raise the head when the body is supine. This head-raising action is a combination of upper cervical extension and lower cervical flexion. The muscle is also active on resisted neck flexion. With the head fixed, it is also an accessory muscle of forced inspiration.

Levator Scapulae

The levator scapulae (Fig. 16-5), is a slender muscle attached by tendinous slips to the posterior tubercles of the transverse processes of the upper cervical vertebrae (C1–4). The levator, located deep to both the upper and the middle parts of the trapezius, can be palpated just deep to the superior border of the trapezius. It descends posteriorly, inferiorly, and laterally to the superior angle and medial border of the scapula, between the superior angle and the base of the spine (Table 25-1). The levator is the major stabilizer and elevator of the superior angle of the scapula. With the scapula stabilized, the levator produces rotation and side bending of the neck to the same side; when acting bilaterally, cervical extension is produced. With a forward head posture, the potential for this extension moment increases.1 This abnormal anterior translation is resisted by tension within the levator scapulae and the ligamentum nuchae.61

The levator is supplied by direct branches of the C3 and C4 cervical spinal nerves and from C5 through the posterior (dorsal) scapular nerve. It is heavily innervated with muscle spindles.

Rhomboids

The rhomboid major is a quadrilateral sheet of muscle, and the rhomboid minor muscle is small and cylindrical (see Chap. 16). Together they form a thin sheet of muscle that fills much of the interval between the medial border of the scapula and the midline. Although the rhomboid minor, with its attachment to the spinous processes of C7 and T1, has a slight association with the cervical spine, the rhomboid major, arising from the spinous processes of T1–5, is inactive during isolated head and neck movements. The two muscles descend from their points of origin, passing laterally to the posterior aspect of the vertebral border of the scapula, from the base of the spine to the inferior angle. Both of these muscles receive their nerve supply from the posterior (dorsal) scapular nerve (anterior (ventral) ramus of C4–5). The principal action of these muscles is to work with the levator scapulae to control the position and movement of the scapula. Both of the muscles are involved with concentric contractions during rowing exercises or other activities involving scapular retraction.

Scalenes

The scalenes (Fig. 25-4) extend obliquely like ladders (scala means ladder in Latin) and share a critical relationship with the subclavian artery. Tightness of these muscles will affect the mobility of the upper cervical spine. In addition, because of their distal attachments to the first and second ribs (Table 25-2), they can, if in spasm, elevate the ribs and be implicated in thoracic outlet syndrome (TOS).62,63

Scalenus Anterior

The scalenus anterior (see Fig. 25-4) runs vertically, behind the SCM on the lateral aspect of the neck. Arising from the anterior tubercles of the C3–6 transverse processes, it travels to the scalene tubercle on the inner border of the first rib. The osteal portion of the vertebral artery and the stellate ganglion are located lateral to the scalenus anterior. Acting from above, the scalenus anterior, like the rest of the scalenes, is an inspiratory muscle, even with quiet breathing.64 Working bilaterally from below, it flexes the spine. Unilaterally, it side bends the spine ipsilaterally and rotates the spine contralaterally. It is supplied by the anterior (ventral) rami of C4, C5, and C6.

Scalenus Medius

The scalenus medius (see Fig. 25-4) is the largest and longest of the group, attaching to the transverse processes of all cervical vertebrae except the atlas (although it often attaches to this) and running to the upper border of the first rib. It is separated from the anterior scalene by the carotid artery, and cervical nerve, and is pierced by the nerve to the rhomboids (posterior (dorsal) scapular) and the upper two roots of the nerve to the serratus anterior (long thoracic). Working unilaterally on the cervical spine, the scalenus medius is an ipsilateral side bender of the neck. Working bilaterally, it is a cervical flexor.

Scalenus Posterior

The scalenus posterior (Fig. 25-4) is the smallest and deepest of the group, running from the posterior tubercles of the C4–6 transverse processes to attach to the outer aspect of the second rib. It functions to elevate or fix the second rib and side bends the neck ipsilaterally. It is innervated by the anterior (ventral) rami of C5, C6, and C7.

Scalenus Minimus (Pleuralis)

The scalenus minimus is a small muscle slip, running from the transverse process of C7 to the inner aspect of the first rib and the dome of the pleura. It is a suprapleural membrane that is often considered to be the expansion of the tendon of this muscle. The muscle functions to elevate the dome of the pleura during inspiration, and is innervated by the anterior (ventral) ramus of C7.65

Platysma

The broad sheet of the platysma muscle is the most superficial muscle in the cervical region (Fig. 25-3). The platysma covers most of the anterolateral aspect of the neck, the upper parts of the pectoralis major, and deltoid, extending superiorly to the inferior margin of the body of the mandible. As a muscle of facial expression, it cannot affect bony motion, except perhaps as a passive restraint to head extension. It is supplied by the cervical branch of CN VII (facial).

Deeper Muscles of the Back

The deep or intrinsic muscles of the back are the primary movers of the vertebral column and head and are located deep to the thoracolumbar fascia. The muscles in all of these groups are segmentally innervated by the lateral branches of the posterior (dorsal) rami of the spinal nerves.

Splenius Capitis

The splenius capitis (Fig. 25-5) extends upward and laterally, from the posterior (dorsal) edge of the nuchal ligament and the spinous processes of the lower cervical and upper thoracic vertebrae (T4–C7) to the mastoid process of the occipital bone just inferior to the superior nuchal line and deep to the SCM muscle.

Splenius Cervicis

The splenius cervicis is just inferior and appears continuous with the capitis, extending from the spines of the third to the sixth thoracic vertebrae to the posterior tubercles of the transverse processes of the upper cervical vertebrae.

The splenius capitis and splenius cervicis muscles are two important head and neck rotators. From their attachments (Table 25-3), it is clear that these two muscles are capable of producing ipsilateral rotation, side bending, and extension at the spinal joints they cross.

Cervical Erector Spinae

The erector spinae complex spans multiple segments, forming a large musculotendonous mass (Fig. 25-6) consisting of the iliocostalis, longissimus, and spinalis muscles (Tables 25-4 and 25-5).

• The iliocostalis cervicis appears to function as a stabilizer of the cervicothoracic junction and lower cervical spine.
• The semispinalis has thoracis, cervicis, and capitis divisions. The obliquus capitis superior (superior oblique) and inferior (inferior oblique) and the rectus capitis posterior major and minor (see Chap. 23) lie underneath the semispinalis capitis and splenius capitis muscles.66 The semispinalis cervicis is a stout muscle that extends superiorly to the spinous process of vertebra C2, functioning as a strong extensor of the lower cervical spine.1
• The interspinales and intertransversarii, which interconnect the processes for which they are named, produce only minimal motion because they can influence only one motion segment and are more likely to function as sensory organs for reflexes and proprioception.67

Deep Neck Flexors

The prevertebral muscles of the neck consist of:

• Longus colli. The longus colli (Fig. 25-4) consists of a vertical portion that originates from the bodies of the first three thoracic and last three cervical vertebrae, an inferior oblique portion that originates from the bodies of the first three thoracic vertebrae, and the superior oblique portion that originates from anterior tubercles of the transverse processes of C3–5. The various portions of the longus colli insert into the bodies of C2–4, the anterior tubercles of the transverse processes of C5–6, and the anterior tubercle of the atlas. The longus colli functions to flex (and assists in rotating) the cervical vertebrae and head. Acting singly, the longus colli side bends the vertebral column. The longus colli is innervated by branches of the anterior primary rami of C2–8.
• Longus capitis. The longus capitis (Fig. 25-4) originates from the anterior tubercles of the transverse processes of C3–6 and inserts onto the inferior surface of the basilar part of the occipital bone. The longus capitis functions to flex (and assists in rotating) the cervical vertebrae and head. It is innervated by the muscular branches of C1–4.
• Rectus capitis anterior. The rectus capitis anterior (RCA) originates from the lateral mass of the atlas and inserts onto the base of the occipital bone in front of the foramen magnum. The RCA flexes and rotates the head and is innervated by the muscular branches of C1–2.
• Rectus capitis lateralis. The rectus capitis lateralis (RCL) originates from the upper surface of the transverse process of the atlas and inserts onto the inferior surface of the jugular process of the occipital bone. The RCL side bends the head to the ipsilateral side and is innervated by branches of the anterior rami of C1–2.

Neurology

The nerve supply to the cervical structures is rather unique because of the association that some of the muscles have with the cranial nerves. The cervical spine is the only region that has more nerve roots than vertebral levels.8

In general, structures supplied by the upper three cervical nerves can cause neck and head pain (see Table 23-1), whereas the mid to lower cervical nerves can refer symptoms to the shoulder, anterior chest, upper limb, and scapular area.68

Cervical proprioceptive input has considerable influence on posture through the tonic neck reflex and on eye movement and accommodation through the cervico-occular and vestibulo-ocular reflexes (see Chap. 3).68–70 It is probably no accident that the two largest postural muscles of the head and neck, the trapezius and the SCM muscles, are partly innervated by the accessory nerve (CN XI).

Vascular Supply

The middle cervical segments are supplied by radicular branches off the extradural vertebral artery and are the most common segments to be affected in vertebral artery disease.71 The vertebral artery is detailed in Chapter 24.

The common carotid artery bifurcates at the middle to upper cervical level into the internal and external carotid arteries. The carotid body, a specialized structure that senses oxygen and carbon dioxide levels in the blood, is located at this bifurcation.8 The carotid sinus, which contains baroreceptors that monitor blood pressure, is located at a point before the bifurcation.8

Cervical Lordosis

The amount of cervical lordosis is a factor of the zygapophyseal joint planes and the cervical IVDs. Under normal conditions, the C4–5 interspace is considered the midpoint of the curve, and the center of gravity (COG) for the skull lies anterior to the foramen magnum. The longus colli has been shown to have an important supporting role on the cervical curve.72

A reduction in the cervical lordotic curve because of injury or abnormal posture results in more weight being borne by the vertebral bodies and IVDs, whereas an increase in the lordosis increases the compressive load on the zygapophyseal joints and posterior elements. Watson and Trout73 have demonstrated a link between a lack of endurance capacity of the upper cervical and deep neck flexors and the forward head posture (see later).

Cervicothoracic Junction

The cervicothoracic junction comprises the C7–T1 segment, although functionally it includes the seventh cervical vertebra, the first two thoracic vertebrae, the first and second ribs, and the manubrium. In addition, the cervicothoracic junction forms the thoracic outlet, through which the neurovascular structures of the upper extremities pass. Lewit74 considers the cervicothoracic junction to be the third major area of the spine for musculoskeletal problems, with the craniovertebral area and the lumbosacral junction being first and second, respectively.

The motions that occur at the cervical spine correspond to motions of the head, although the range of head movement bears little relation to the range of neck movement and that the total range is the sum of both the head and the neck motions.75

The cervical spine is a complex mechanical linkage composed of multiple degrees of freedom of movement about each of its joints and at least 20 pairs of muscles, many of which are capable of performing similar actions.50 It is estimated that the osseoligamentous system contributes 20% to the mechanical stability of the cervical spine while 80% is provided by the surrounding neck musculature.76 The role of the ligaments in stabilization occurs mainly at end of range postures,77 while the muscles supply dynamic support in activities around neutral- and mid-range postures.78

At the zygapophyseal joints, there is a sagittal range of 50–80 degrees in each direction of flexion and extension.79 The only significant arthrokinematic motions available to the zygapophyseal joint are an inferior, medial glide of the inferior articular process of the superior facet during extension and a superior, lateral glide during flexion. Segmental side bending is, therefore, extension of the ipsilateral joint and flexion of the contralateral joint. Rotation, coupled with ipsilateral side bending, also involves extension of the ipsilateral joint and flexion of the contralateral. Because of their multiple insertions, many of the neck muscles have multiple functions or can change their function depending on the initial position of each vertebral joint and the degree to which the joints are free to move in each of the planes of motion.50 Thus, a voluntary motor task in the head and neck can be accomplished through a variety of combinations of kinematic and muscle actions. Considering that most functional daily tasks are performed in and around midrange postures, the muscles controlling the cervical spine are subject to constant external and internal forces.78

Flexion

Flexion may be divided into three sequential phases.80,81 The initial phase begins in the lower cervical spine (C4–7) where C6–7 makes its maximum contribution followed by the C5–6 segment and then by C4–5. Motion in the second phase occurs initially at C0–2 followed by C2–3 and C3–4. The first phase of motion occurs again at the lower cervical spine (C4–7) initially, with the C4–5segment followed by C5–6 then the C6–7 segment.80,81

At the segmental level, flexion is described as an anterior osteokinematic rock tilt of the superior vertebra in the sagittal plane, a superoanterior glide of both superior facets of the zygapophyseal joints, and an anterior translation slide of the superior vertebra on the IVD (see Fig. 25-7). This produces an anterior (ventral) compression and a posterior (dorsal) distraction of the cervical disk. The uncovertebral joint lies on, or very near to, the axis of rotation for flexion and extension. Consequently, the main arthrokinematic motion that seems likely to be occurring here is an anterior spin (or very near spin).82 This arthrokinematic spin appears especially probable, as impairments of the uncovertebral joint seem to be unaffected by flexion or extension. Thus, uncovertebral restrictions may be detected in all cervical positions, although flexion partly disengages the joint because of its posterior position on the vertebra.82

Although all of the following anatomic movement restrictors act to some degree on most of the components of flexion, they act particularly on the associated movement component.

• Anterior osteokinematic motion is restrained by the extensor muscles and the posterior ligaments (posterior longitudinal, interspinous, and ligamentum flavum).
• Superoanterior arthrokinematic is restrained by the joint capsule, whereas translation is restrained by the disk and the nuchal ligament.

Extension

Extension is described as a posterior osteokinematic sagittal rock, an inferoposterior glide and approximation of the superior facets of the zygapophyseal joints, and a posterior translation of the vertebra on the disk (see Fig. 25-8). The uncovertebral joint undergoes a posterior arthrokinematic spin. The osteokinematic motion of extension is restricted by the anterior prevertebral muscles and the ALL. The arthrokinematic motion is restricted by the zygapophyseal joint capsule.82 The IVD restrains the posterior translation.

Side Bending

Side bending (lateral flexion) is an ipsilateral osteokinematic rock, a superoanterior glide of the contralateral superior facet, and a posteroinferior glide of the ipsilateral facet (see Fig. 25-9). In addition, there is a contralateral translation of the vertebra on the disk, an inferomedial glide of the ipsilateral uncovertebral joint, and a superolateral glide of the contralateral uncovertebral joint. A composite curved translation results. This curve is formed by the superoinferior linear glides of the zygapophyseal joints, the oblique inferomedial and superomedial glides of the uncovertebral joints, and the linear translation across the disk.82

The osteokinematic rock can be limited by the contralateral scalenes and intertransverse ligaments. The uncovertebral and zygapophyseal arthrokinematic motions can be limited by the joint capsule, and the translation is limited by the IVD. If the side bending is limited but the translation is okay, it is unlikely that the joint complex (the zygapophyseal joint, disk, or uncovertebral joint) is impaired; instead, these findings may implicate adaptive shortening of the soft tissues.82 However, if the translation is also limited, a problem with the joint complex also probably exists.

Rotation

Rotation is chiefly an osteokinematic motion of the vertebra about a vertical axis that is coupled with ipsilateral side bending (see Fig. 25-10). Presumably, the translation follows the side bending (i.e., contralateral), resulting in the same uncovertebral and zygapophyseal arthrokinematic motions as does side bending.82

Muscle Control

The control of head and neck postures and movements is a complex task, especially in the presence of pain or dysfunction. The muscle groups of the cervical region may be divided into those that sustain postures or stabilize the segments and those that produce movement.84–86 Considerable biomechanical, physiological and clinical research in both the cervical and lumbar regions has been undertaken which supports Bergmark's86,87 model for a functional division between the deep and more superficial muscles in their relative contributions to spinal support and control.78 According to this model, the more superficial multisegmental (global) muscles have the responsibility for maintaining equilibrium of external forces (torque production and control of the head) so that the load transmitted to the spinal segments can be controlled efficiently by the deep intersegmental (local) muscle system.68,78,86

The SCM (anteriorly) and the semispinalis capitis and splenius capitis (posteriorly) are thought to be the global muscles of the neck, whereas the local system is thought to comprise the longus capitis and colli (Table 25-2),72 semispinalis cervicis, and multifidus.88 The longus colli and posterior (dorsal) neck muscles form a muscle sleeve that surrounds the cervical column to support the cervical spinal segments in functional movements.72

Patients with neck pain have been found to demonstrate generally less torque production (strength and endurance) in all planes, with a greater loss in the cervical flexors than extensors.89 However, addressing strength alone in research and exercise programs may oversimplify the problems in the neuromuscular system associated with neck pain.78 Recent research has recognized the vital role that activation of the deep neck flexor muscles plays in supporting the cervical segments and the cervical curve (see “Muscle Function Testing: Deep Neck Flexors” section later).72,88,90 Indeed, impairment in the axioscapular-girdle muscles has been linked clinically to cervical pain syndromes.84,91–95 The nature of the impairment in the cervical and cervicobrachial muscle systems indicates the need for careful and precise movement analysis and muscle testing to appreciate and accurately define the problem.78

The cervical spine is an area with a high potential for serious injury, which makes this a region of the body that needs to be examined with caution, especially when there is a history of acute and recent trauma of the neck, because of the potential for the examination itself to be harmful.96 Although most conditions involving neck and upper limb symptoms can be diagnosed after a careful history and physical examination, in cases of significant trauma, imaging studies may be required to exclude a fracture or instability. Where possible, the patient should be examined for central and/or peripheral neurologic deficit, neurovascular compromise, and serious skeletal injury, such as fractures or craniovertebral ligamentous instability.

Winkel and colleagues97 clinically categorize cervical disorders by the location of symptoms and the etiology of each condition:

• Local cervical syndrome (LCS). This syndrome manifests with local neck complaints, resulting from cervical muscle strain, ligament sprain, or a primary or secondary disk-related condition.
  • A primary disk-related LCS is characterized by symptoms that may result from a protrusion, prolapse, or extrusion of the disk.
  • A secondary disk-related LCS is characterized by symptoms resulting from gradual changes in the cervical spine that have been generated by previous degradation of the IVD. These changes include internal disk disruption and synovitis or irritation of the zygapophyseal and uncovertebral joints. In the cervical spine, myofascial pain may be a secondary tissue response to an IVD or zygapophyseal joint injury.98 The cervical zygapophyseal (facet) joints can be responsible for a significant portion of chronic neck pain. Established referral zones for the cervical zygapophyseal joint99,100 overlap both myofascial and dermatomal pain patterns. Cervical zygapophyseal joint pain is typically unilateral and is described by the patient as a dull ache. Occasionally, the pain can be referred into the craniovertebral or interscapular regions.
• Cervicobrachial syndrome. This syndrome includes symptoms in the local cervical region, as well as in one or both upper extremities, as a result of nerve root irritation through compression or tension of the nerve root.
• Cervicocephalic syndrome. This syndrome is characterized by complaints in both the neck and the head and includes symptoms such as dizziness, tinnitus, and headache. These symptoms may result from articular, ligamentous, neurologic, organic, or vascular sources.
• Cervicomedullary syndrome. This syndrome is characterized by spinal cord symptoms associated with cord compression at the cervical spine (cervical myelopathy).

Clearing tests for the cervical spine include

• vertebral artery tests;
• Sharp–Purser test;
• articular stability tests;
• transverse ligament test;
• alar ligament test;
• temporomandibular joint (TMJ) assessment.

Once damage to the vertebral artery (see Chap. 24) and transverse ligament (see Chap. 23) has been ruled out, the most likely pain candidates are assessed first. These include the bone, muscles, ligaments, zygapophyseal joints, and IVD. In addition, because of its close proximity, a quick examination of the TMJ should be performed to rule out pain referral from this joint (see Chap. 26). The examination must be graduated and progressive so that the testing can be discontinued at the first signs of serious pathology.96 An examination and treatment algorithm for the mid-lower cervical spine is outlined in Figure 25-11.

History

The most common symptoms of cervical disorders are ongoing or motion-induced neck or arm pain, or both, and suboccipital headache.12 In addition to the questions listed under History in Chapter 4, the clinician should obtain the following information.

The clinician must determine whether the trauma occurred and the exact mechanism. In acute sprains and strains, patients typically relate an activity that precipitated the onset of their symptoms. This may be lifting or pulling a heavy object, an awkward sleeping position, a hyperextension injury, or prolonged static postures. In whiplash-associated disorders (WADs), patients generally describe an accident in which they were unexpectedly struck from the rear, front, or side. Rotational injuries may also occur. If there were neurologic symptoms following the trauma (paresthesias, dizziness, tinnitus, visual disturbances, or loss of consciousness), more severe damage should be suspected.101 If the patient reports electric shock-like symptoms down the spine with neck flexion (Lhermitte's sign), the clinician should consider the possibility of inflammation or irritation of the meninges.102–104 A traumatic mechanism of injury with complaints of nonspecific cervical symptoms that are exacerbated in the vertical position, and relieved with the head supported in the supine position, is suggestive of cervical instability, especially if the patient reports that dysthesias of the face occur with neck movement.105–107

For the purposes of the examination, it is important to establish a baseline of symptoms so that the clinician is able to determine whether a particular movement aggravates or lessens the patient's symptoms. The history can provide the clinician with information as to the location of the patient's symptoms (head, neck, shoulder, arm, and hand), the nature of the symptoms (constant, intermittent, or variable), the type of symptoms (pain, paresthesia, numbness, weakness, and stiffness), the severity of the condition, and the activities or positions that appear to aggravate or improve the patient's condition. It is also important to determine the type of work the patient does and whether that work involves sustained postures, the potential for eye strain, repetitive motions of the head, neck and upper extremity, or heavy lifting. Symptoms associated with coughing and sneezing are often associated with disk pathology. Radicular pain may be accompanied by sensorimotor symptoms.12

The patient's chief complaint should be determined. The clinician should determine the location and boundaries of the symptoms. All symptoms present should be recorded on a body diagram, even those that may initially appear unrelated. If pain is the major symptom, the clinician should attempt to quantify the pain using a pain rating scale. It is also appropriate at this time to establish the patient's goals.

Asking the patient to describe his or her symptoms over a 24-hour period can provide the clinician with valuable information about the severity, the positions and activities that aggravate or relieve the symptoms, and the duration of the symptoms. Patients who report difficulty in sleeping because of pain may have an inflammatory condition, but the more insidious causes of night pain, such as malignancy, must be ruled out. The patient's sleeping position and habits should be investigated. Cervical symptoms often are increased when a foam or very firm pillow is used.108 Sleeping in the prone position requires adequate cervical and upper thoracic rotation. Some degree of cervical extension also is required, depending on the number and type of pillow used. The onset of symptoms may also provide clues as to the type of tissue involved. Muscle or ligamentous pain may either occur immediately following trauma or be delayed for several hours or days. Bone pain usually occurs immediately.

The reports of headaches or facial pain, depending on frequency and severity warrant special attention (see Systems Review).

It is important for the clinician to determine whether the patient has had successive onsets of similar symptoms in the past, because recurrent injury tends to have a detrimental effect on the potential for recovery. If the patient has had a recurrent injury, the clinician should note how often, and how easily, the injury has recurred and the success or failure of previous interventions.

The clinician must determine whether there are musculoskeletal symptoms elsewhere. It is well established that the head, neck, upper thoracic regions, and upper extremities can be sites of referred pain. Thoracic interscapular pain, at a point level with T4–5, is a very common complaint, especially in women.2 This pain is thought to be posture related.

Neck pain accompanied by widespread musculoskeletal pain raises the strong possibility of fibromyalgia, whereas neck pain with synovitis of peripheral joints suggests an inflammatory arthropathy, such as rheumatoid arthritis.111 Myofascial pain syndromes are characterized by generalized aching and the presence of trigger points (see Chap. 10). The basic pathologic impairment in myofascial pain has yet to be substantiated.112,113 Pain that is constant in nature and unrelated to rest or activity may be inflammatory in origin, in which case physical therapy and, specifically, manual therapy may be inappropriate.114

A report of diffuse nonspecific neck pain that is exacerbated by neck movements is suggestive of mechanical neck pain, cervical facet syndrome,115 or a cervical strain/sprain.116 Conditions that have a mechanical origin usually are improved with rest, although they may worsen initially on retiring.117 Pain caused by sustained positions and postures, such as the upper crossed postural syndrome,84 may awaken the patient at night but usually is relieved with a change of position.

Systems Review

General health questions provide information about the status of the cardiopulmonary system, the presence or absence of systemic disease, and medications the patient may be taking that might affect the examination or intervention. Warning signs in the cervical region include

• unexplained weight loss;
• evidence of compromise to two or three spinal nerve roots;
• gradual increase in pain;
• expansion of pain in terms of the regions involved;
• spasm with passive range of motion of the neck;
• visual disturbances;
• painful and weak resistive testing;
• hoarseness;
• limited scapular elevation;
• Horner's syndrome;
• T1 palsy (weakness and atrophy of the intrinsic muscles of the hand);
• arm pain in a patient who is younger than 35 years or in a patient for more than 6 months;
• side bending away from the painful side that causes pain (if this is the only motion that causes pain).

It must also be remembered that all cervical patients, especially the ones with a history of a hyperextension mechanism, are at potential risk of serious head and neck injuries, including vertebrobasilar injury (Chap. 24) and cervical myelopathy. Cervical myelopathy (Table 25-6), involving an injury to the spinal cord itself, is associated with multisegmental paresthesias and upper motor neuron (UMN) signs and symptoms such as spasticity, hyperreflexia, visual and balance disturbances, ataxia, and sudden changes in bowel and bladder function. Early indicators of this condition include reports of symptoms in multiple extremities and clumsiness when performing fine motor skills. Myelopathy may occur with compression of the spinal cord and is more likely to occur at the C5–6 level, because in this region the spinal cord is at its widest and the spinal canal, at its narrowest.118 Usually, narrowing of the spinal canal occurs during the end stages of degenerative disease, although structural anomalies, such as a narrowed trefoil canal or shortened pedicles, can result in congenital stenosis.8 Depending on the cause, the onset of myelopathy can be sudden or gradual.

The following signs and symptoms demand a cautious approach or an appropriate referral:

• recent trauma (occurring up to 6 weeks earlier);
• an acute capsular pattern;
• severe movement loss, whether capsular or noncapsular;
• strong spasm;
• paresthesia
• segmental paresis;
• segmental or multisegmental hyporeflexia or areflexia;
• UMN signs and symptoms (see Chap. 3). These can include reports of neck pain with bilateral upper extremity symptoms and occasional reports of loss of balance or lack of coordination of the lower extremities.
• Constant or continuous pain;
• moderate-to-severe radiating pain;
• moderate-to-severe headaches;
• tinnitus;
• history of loss of consciousness;
• memory loss or forgetfulness;
• difficulties with problem solving;
• reduced motivation;
• irritability;
• anxiety or depression;
• insomnia.

Neurologic Symptoms

The presence of neurologic symptoms, including sympathetic symptoms (e.g., blurred vision, sweating, tinnitus), deserves special attention. Many of the symptoms that occur in an upper limb have their origins in the neck. The patient with neck trauma can report seemingly bizarre symptoms, but these need to be heeded until the clinician can rule out serious pathology. Cervical radiculitis is most commonly associated with spinal nerve root irritation. Peripheral symptoms can also be caused by a host of other conditions, including TOS or an isolated peripheral nerve lesion.119

The systems review must include questions that will elicit any symptoms that might suggest a CNS condition or a vascular compromise to the brain. For example, lower limb symptoms associated with neck motions, difficulty walking, poor balance, or bowel or bladder dysfunction. One of the earlier indications of a balance disturbance can be elicited during the history or systems review with correct questioning. A simple question such as “Do you have difficulty with walking or with balance?” can provide the clinician with valuable information. Positive responses may indicate a cervical myelopathy or systemic neurologic impairment.120 The neurologic examination, if appropriate, attempts to differentiate between nerve root and spinal cord compression. The presence of any UMN sign or symptom requires an immediate medical referral.

Vascular Compromise

A history of dizziness, falling, faintness, or seizures always warrants further investigation. It is not always an easy task for the clinician to determine whether the presenting dizziness is the result of a disturbed afferent input from the cervical spine, which can be extremely rewarding to treat, or has a more serious cause.96 For example, dizziness provoked by head movements may indicate an inner ear or vertebral artery problem. A history of falling without loss of consciousness (drop attack) is strongly suggestive of vertebral artery compromise.121 Testing of the vertebral artery (see Chap. 24) should be considered if the observation and history reveal any of the signs and symptoms that have been linked, directly or indirectly, to vertebral artery insufficiency. These include

• Wallenberg's, Horner's, and similar syndromes;
• bilateral or quadrilateral paresthesia;
• hemiparesthesia;
• ataxia;
• nystagmus;
• drop attacks;
• periodic loss of consciousness;
• lip anesthesia;
• hemifacial paresthesia or anesthesia;
• dysphasia;
• dysarthria.

Headache or Facial Pain

Does the patient have headaches and, if so, where? What is their frequency and intensity? Does a position alter the headache? If the patient reports relief of pain and referred symptoms with the placement of the hand or arm of the affected side on top of the head (Shoulder abduction/Bakody's sign), this usually is indicative of a disk lesion of the C4 or C5 level.122

A history of headaches may or may not be benign, depending on the frequency and severity. Differential diagnosis is important, especially in light of the fact that there is considerable overlap in symptoms among tension headaches; cervicogenic headaches (see Chap. 23); cervical, trigeminal, and glossopharyngeal neuralgia (see Chap. 5); the headache associated with Lyme disease (see Chap. 5); migraines without aura (see Chap. 5); and TMJ dysfunction (see Chap. 26).123 Cervicogenic headaches, which can be mild, moderate, or severe, tend to be unilateral and located in the suboccipital region, with referral to the frontal, retro-orbital, and temporal areas.69,124 The more serious causes of headache without a history of trauma include spontaneous subarachnoid hemorrhage, vertebral artery compromise, meningitis, pituitary tumor, brain tumor, and encephalitis (see Chap. 5).

Facial pain can be the consequence of temporomandibular dysfunction, temporal arteritis, acute sinusitis, orbital disease, glaucoma, trigeminal neuralgia, referred pain, and herpes zoster (see Chap. 5).

Observation

Static observation of general posture, as well as the relationship of the neck on the trunk, and the head on the neck, is carried out while the patient is standing and sitting, both in the waiting area and in the examination room (see Chap. 6). Once in the examination room, the patient is asked to assume an upright neutral postural position from a relaxed sitting position. This can help the clinician to gain an idea of which muscle strategy the patient is using to support the natural spinal curves.78 A major contributor to cervicogenic pain is a lack of postural control resulting from poor neuromuscular function.85,123,125,126 Sustained postures, or fatigue overloading of the deep spinal and postural muscles, can result in increased joint compressive forces and inefficient movement strategies.112,113,127,128 A good pattern when assuming an upright neutral postural position would involve the pelvis being brought into an upright neutral position, with the formation of a low lumbar lordosis (lumbar multifidus) rather than with thoracolumbar extension (thoracopelvic extensors).78 Postural misalignment of the head on the trunk is associated with complaints of pain in the neck and shoulder region and TMJ dysfunction, but is also observed in asymptomatic individuals.

The clinician should look for:

• Hair quality (i.e., brittle hair due to thyroid problems).
• The position of the patient's head. If it is shifted to one side, a disk protrusion may be present; if deviated, acute arthritis may be the cause. Severe or constant pain usually is manifested by the patient constantly changing his or her posture or remaining very still.
• Evidence of the patient being a mouth breather. Mouth breathing encourages forward head posture.
• Evidence of skin cancer, such as unusual looking moles.
• Torticollis.
• Sprengel's deformity, a congenital elevation and medial rotation of the scapula, which gives the patient the appearance of having no neck on one side, secondary to a high-riding scapula.
• Scars (long, transverse scars indicative of cervical surgery), lumps, rashes, thyroid enlargement (goiter), skin discoloration, or other lesions.
• Scoliosis in the thoracic spine.
• Soft tissue contours that can highlight swelling, muscle atrophy or hypertrophy.
• The position of the thoracic and cervical curves as well as the craniocervical posture.
• Scapular position in association with muscle bulk/tone of the axioscapular-girdle muscles both anteriorly and posteriorly.78 Ideally, the resting scapulae should sit such that the superior angle lies level with the T2 or T3 spinous process, the root of the spine of the scapula level with the T3 or T4 spinous process, and the inferior angle level with the T7–9 spinous process.129 Common “abnormal” postural positions of the scapula include a downwardly rotated and protracted scapula, which is often associated with a dominant action of the levator scapular and an increase resting length of the trapezius.78,93,128 Conversely the scapula may appear slightly elevated, indicating an adaptively shortened upper trapezius, protective positioning, or neural tissue mechanosensitivity.78
• Bone deformities (i.e., endocrine disorders). Conditions include abnormal bony enlargement of the face, jaw, hands, and feet (acromegaly); a “moon-faced,” buffalo hump (fatty deposits) at the neck, axial obesity, generalized atrophy of muscles, and kyphotic posture due to excess cortisol production (Cushing's syndrome) or bulging eyes due to excess thyroid hormone (Graves disease).130
• Autonomic skin changes (increased sweating, trophic changes, and texture changes).
• Birthmarks.
• Changes in the patient's facial expression suggesting pain with transitional movements.

• The forehead should be vertical.
• The tip of the chin should be in line with the manubrium. If the chin is anterior to the manubrium, a forward head is present (see later discussion). The amount of forward head can be measured in two ways. The simplest method is to measure the distance between the tip of the chin and the manubrium. The more complex and expensive methods involve the use of computer-assisted digitizing systems.
• The clinician should observe the cervical lordosis. A flattened lordosis may be associated with stretched posterior cervical ligaments and extensor muscles, and adaptively shortened cervical flexors. An excessive lordosis is associated with a forward head and an adaptive shortening of the posterior ligaments and neck extensor muscles.
• The ears are inspected for signs of asymmetry, inflammation, rashes, lumps, scars, or other lesions. Discharge from within the external ear canal may indicate infection (i.e., otitis externa).130

• The clinician should assess muscular asymmetry, especially in the upper trapezius and SCM (see also Chap. 16).
• The spinous process of the axis should be in the midline.
• Usually the shoulder on the dominant side is slightly lower than that on the nondominant side.
• Is there any atrophy of the deltoid suggesting axillary nerve palsy?
• As the patient rotates the head to each side, the tips of the transverse processes of the atlas should be felt to rotate anteriorly and then posteriorly. Both sides are compared. The procedure is repeated for side bending. The transverse process should become less prominent and should approximate the mastoid process, on the side of the side bending.

• The clinician should assess whether the patient's head is shifted to one side. A cervical disk protrusion (C3–4 or C4–5) can produce a horizontal side shift of the head.82 This side shift allows the patient to maintain eye level.
• A slight tilt of the head is normal but may indicate an upper cervical joint dysfunction.
• The eyes should be inspected for ptosis (droopy eyelid). The patient should be instructed to look up, while the clinician gently pulls down both lower eyelids to inspect the conjunctiva (for signs of anemia—bluish appearance and conjunctivitis—redness) and sclera (for jaundice—yellowish appearance).130 The eyes should also be observed for other signs of discoloration, discharge, and any deformity of the iris. The clinician should also note any evidence of nystagmus (see Chap. 3), which may be positional and fatigable and which may be caused by a lesion anywhere from the eyes to the midbrain.131 A Dix–Hallpike test (see Chap. 3) should be carried out in patients suspected of having a vestibular disorder.131
• Facial symmetry. The clinician visually splits the mass of the head into two vertical halves. Cerebral asymmetries in form and volume, associated with cranial asymmetries, are a common feature of the human race and are often associated with facial asymmetries.132,133 This asymmetry is, in many cases, related to asymmetric cerebral growth, which is mostly accomplished in utero,134,135 although it may also have a local origin, for instance, in the case of mandibular asymmetry. Facial asymmetry can also be due to facial nerve (CN VII) paralysis or partial weakness. The trigeminal nerve (CN V) may be involved if asymmetry (deviation) is observed in the mouth due to muscle weakness or atrophy on one side of the jaw.130

Forward Head

The cervical and upper thoracic regions are highly prone to postural and degenerative dysfunctions. Poor posture and dysfunctional movement patterns may alter the normal segmental motion of the neighboring regions (Table 25-7). A forwardly inclined head increases the stresses at the cervicothoracic junction and increases the craniovertebral lordosis, producing compensatory occipitoatlantal extension.

In the forward head posture, the upper trapezius can be maintained in a constant state of contraction33 (Table 25-7). This constant state of contraction can also occur as a result of a protective mechanism for the cervical joints, ligaments, or IVD.136

This hypertonicity of the upper trapezius produces a paravertebral area that is broader and more prominent than normal. Tightness or adaptive shortening of the levator scapulae results in the contour of the neckline appearing as a double line (wave) where the muscle inserts into the scapula.84 This is described as Gothic shoulders, because it is reminiscent of the form of a Gothic church tower.

Movement patterns performed on a poor postural base contribute to repetitive microtrauma of cervical structures. These structures include the zygapophyseal facets, IVD, ligaments, joint capsules, and muscles, all of which are capable of propagating the cycle of pain and dysfunction.137,138

Active Range of Motion

The clinical examination of the mobility of the cervical spine should consist of a comparison between active and passive ranges and coupled movements of the cervical spine. Knowledge of cervical anatomy and kinematics should assist the clinician in determining the structure responsible, based on the pattern of movement restriction noted in the physical examination (Table 25-8). The range of motion assessment of the craniovertebral region is described in Chapter 23.

The range of motion available at the cervical spine is the result of such factors as the motion available at each segment, the shape and orientation of the zygapophyseal joint surfaces, the inherent flexibility of the restraining ligaments and joint capsules, the height and pliability of the IVD, and the range available in the craniovertebral and upper thoracic joints. A movement restriction is a loss of movement in a specific direction, and one in which a movement toward or away from the restriction may alter the degree and location of those symptoms. When cervical range of motion (CROM) is painful or restricted, muscle pathology is suggested if the restricted motion exists in the direction opposite to the action of the involved muscles. The clinician can apply resistance to the indicated muscle group(s) to verify this hypothesis.

Because of the close relationship of the shoulder to the cervical spine, active elevation of each upper extremity should be assessed to rule out symptom reproduction from the shoulder movements. If there is a loss of one of the cervical motions, the restricted motion should be examined more closely by separating the motion into its various components. For example, full cervical rotation requires motion at the craniovertebral joints, particularly the atlantoaxial joint, as well as segmental rotation at each of the cervical segments.

The major movements that are assessed clinically are rotations out of neutral position flexion–extension, and side bending (Fig. 25-12A–D). The most painful movements are performed last so that no residual pain is carried over from the previous movement. The dual inclinometer method recommended in the American Medical Association's Guides to the Evaluation of Permanent Impairment144 is often considered the clinical standard for assessing cervical ROM in the clinic.145,146 This method requires accurate identification of anatomic landmarks (Table 25-9). Both inter- and intra-rater reliability studies have shown the inclinometry method to be reliable.147–150 Others dispute this conclusion and contend that the inclinometer method is flawed and should not be used in clinical settings.151,152 Using the inclinometer technique, the normal active ranges of motion for the cervical spine are as follows:

• forward flexion: 45–50 degrees;
• extension: 85 degrees;
• side bending: 40 degrees;
• rotation: 70–90 degrees.

The CROM instrument, introduced on the market by Performance Attainment Associates (Roseville, MN), measures the cervical range of motion for flexion, extension, side bending, and rotation using separate inclinometers. These inclinometers are attached to a frame similar to that for eyeglasses: one in the sagittal plane for flexion–extension, a second in the frontal plane for side bending, and a third in the horizontal plane for rotation.141 Two of these inclinometers have a gravity-dependent needle (in the sagittal and frontal planes), and the other has a magnetic needle (in the horizontal plane).141 A magnetic neck brace is worn by the patient. Several researchers have studied the instrument to investigate its intrarater and interrater reliability. Youdas and colleagues151 reported and intraclass correlation coefficient (ICC) varying from 0.73 to 0.95 and an interrater reliability of 0.73 to 0.92 for six cervical movements assessed in 20 patients with orthopaedic disorders.141 Capuano-Pucci and colleagues147 obtain similar results with 20 healthy subjects.141 In a study by Tousignant and colleagues,141 which attempted to estimate the criterion validity of the CROM goniometer using a healthy population found the device to be valid for measurements of cervical flexion and extension. In a more recent study, which compared range of motion measurements using a CROM goniometer and an optoelectronic system (OPTOTRAK), Tousignant et al.142 reported that the CROM device showed excellent criterion validity for measurements of cervical rotation. Wainner et al.153 used an inclinometer and a goniometer in 50 patients with suspected cervical radiculopathy or carpal tunnel syndrome. The results of this study are summarized in Table 25-10.

Whichever method is chosen, it is important remember that, as with other joints in the body, the range of motion in the cervical spine may vary according to a number of factors including the structural ones already mentioned. The available range of motion may be reduced based on the individual's age, neck girth and length, body habitus, diurnal changes,154 neurologic disease, or other factors unrelated to the disability for which the exam is being performed. Without taking body size into account, measurements may underestimate or overestimate range of motion.155 The decrease due to age is probably because of the development of degenerative changes, the only exception being the rotation available at C1-2, which may increase.156 Gender influences on cervical mobility are somewhat more controversial. Dvorak and colleagues156 reported women having greater cervical range of motion compared with men, whereas other studies have shown men have greater available flexion,157,158 women have a greater range in cervical extension only,146 or that that gender is not a variable in cervical range of motion.159

Biomechanical studies have shown that during flexion of the cervical spine, the segments below the second vertebra are blocked.12 Therefore, rotation out of maximum flexion of the cervical spine occurs in the atlantoaxial joint. However, rotation out of maximum extension occurs predominantly in the middle and lower cervical spine but includes the atlantoaxial joint, as well.160

Each of the active motions is tested with a gentle overpressure applied at the end of range if the active range appears to be full and pain free. With the exception of rotation, the weight of the head usually provides sufficient overpressure. It is necessary to apply overpressure even in the presence of pain, in order to achieve an end-feel. If the application of overpressure produces pain, the presence of an acute muscle spasm is possible. Caution must be taken when using overpressure in the direction of rotation, especially if the rotation is combined with ipsilateral side bending and extension, because this can compromise the vertebral artery.161 Given the variability in CROM in the literature even with “normal” patients, recording absolute ranges of motion are perhaps not as important in the presence of pain and dysfunction as the assessment of:

• Quality and quantity of the motion. Quantity and quality of movement refers to the ability to achieve end range with curve reversal and without deviation from the intended movement plane.162
• Symptoms provoked. According to McKenzie, the use of repeated movements to provoke symptoms helps to differentiate between the postural, dysfunction, and derangement syndromes (see Chap. 22). For example, pain of postural origin does not occur with repeated movements and does not limit movement in any direction but is felt only when the patient is stationary or when static loading has been prolonged. In contrast, the pain experienced in the dysfunction syndrome is felt immediately when movement reaches the end of the limited range but stops immediately when the end range position is released. In addition, the pain felt by the patient with a dysfunction syndrome is always intermittent and is the same each day, provided that their activity levels are consistent. In the derangement syndromes, the symptoms can be produced or abolished, increased or decreased, or centralized or peripheralized in response to repeated movements or sustained positions.
• Willingness of the patient to move.
• Presence of specific patterns of restriction. According to Cyriax,163 the capsular pattern of the cervical spine is full flexion in the presence of limited extension, and symmetric limitation of rotation and side bending.

When interpreting the motion findings, the position of the joint at the beginning of the test should be correlated with the subsequent mobility noted, because alterations in joint mobility may merely reflect an altered starting position.

Flexion

An assessment of gross range of motion of cervical flexion is performed (Fig. 25-12A), and the clinician makes note of any motion that reproduces or enhances the symptoms and the location of the symptoms. Considerable emphasis should be placed on the amount and quality of flexion available, and the symptoms it provokes, because flexion is the only motion normally tolerated well by the cervical spine. If the patient has poor concentric control of the deep neck flexors, the SCM will initiate the flexion movement, which will result in the jaw leading the movement instead of the nose (the SCM initially protrudes the chin before flexion occurs). The extreme of cervical flexion is normally found when the chin is able to reach the chest with the mouth closed, although a gap of up to two finger widths is also considered normal.

If end-range flexion is immediately painful, meningitis or acute radicular pain should be ruled out. If the pain is felt after a 15–20-second delay, ligament pain should be suspected. The most common restrictions to cervical flexion are an upper thoracic or cervicothoracic restriction or an occipitoatlantal joint restriction. If, during flexion, the patient pivots the head and neck over a hypomobile and fixed cervicothoracic region, excessive motion will be noted at the levels of C4–6.

Flexion may also be limited by acute or severe trauma (muscle spasms straighten the lordosis), fracture dislocations, or IVD dysfunction.

Extension

The patient is asked to extend the neck (Fig. 25-12B). Normal extension motion allows the face to be parallel with the ceiling. The deep cervical flexors with their extensive longitudinal intersegmental attachments from the upper thoracic spine to the skull are best suited to control extension.78 If the patient has poor eccentric control of the deep neck flexors, two characteristic patterns of movement are evident78:

• There is minimal, if any, movement of the head posteriorly during extension.
• At some point during the extension, the head appears to drop or translate backward.

The return from a fully extended position to a neutral upright position requires a coordinated concentric contraction of the cranial cervical flexors.

Cervical flexion or cervical extension can provoke dizziness. This finding is thought to result from an osteophytic compression on the posterolateral aspect of the transverse foramen by the inferior articulating surface of the zygapophyseal joint.164 Cervical distraction can be applied at the point of symptom provocation. If this maneuver increases the symptoms, manual or mechanical traction should not be part of the intervention plan.

Rotation

With rotation, the chin should be in line with the acromioclavicular joint at the end of rotation (see Fig. 25-12C).

Limitation of or pain on cervical rotation usually suggests pathology at the C1–2 (atlantoaxial) segment, because most rotation occurs at this joint.111 However, if a patient is able to achieve 40–50 degrees of cervical rotation while maintaining eye level, atlantoaxial involvement is unlikely. If, on the other hand, the neck has to side bend early in the active rotation range in order to achieve full motion, the atlantoaxial joint is likely to be involved. If full rotation is limited and cannot be achieved even with the substitution of neck side bending, the problem is likely with the mid-to-low cervical spine segments.

Two screening tests can be used to highlight the level of a rotation restriction. Both of the tests utilize rotation of the neck, with the neck in various amounts of flexion.

1. Rotation with the neck in full side bending is reported to test the C1–2 level.

2. Rotation with the neck in a chin tuck tests the C2–3 level.

Side Bending

Side bending is performed to the left and right, while the ipsilateral and contralateral shoulder are monitored for movement by the clinician as stabilization of the ipsilateral shoulder merely tests the length of the upper trapezius, Fig. 25-12D.) The range of side bending is always greater in the supine than in the sitting position. Active side bending is typically the first motion to demonstrate problems of the cervical spine.165 Restricted cervical side bending could be the result of joint restriction, muscle tightness, or lack of pain-free movement or extensibility of the neural tissues.68

Finally, if in the history, the patient has reported that repetitive movements or sustained postures have caused problems, these should be reproduced in an attempt to provoke the symptoms.

In those situations where the patient does not have full active range of motion and even in those situations when overpressure has been applied at the end of active range of motion to determine the end-feel, passive range of motion must be assessed. This is best performed with the patient in supine to relax the muscles. Due to this muscle relaxation, passive range of motion in supine is greater than in sitting, particularly with side bending (approximately 45 degrees in sitting but 75 to 80 degrees in supine), so an assessment of the end-feel in sitting can often be misleading. With each of the cervical motions, the end-feel should be a solid tissue stretch. As with the active motions, the most painful movements are performed last. Further assessment of passive movements can include position testing, and passive physiological intervertebral motion testing (see Differing Philosophies).

Combined Motion Testing

Because normal cervical function involves complex and combined motions, and because symptoms may only occur with these combined motions, combined motion testing may need to be assessed. Combined motion testing typically occurs when the testing of single plane motions (flexion, extension, side bending, and rotation) and end-feels were found to be normal and pain-free.

Using a biomechanical model, a restriction of cervical extension, side bending, and rotation (Fig. 25-13) to the same side as the pain is termed a closing restriction. This restriction is the most common pattern producing distal symptoms. However, a limitation in cervical flexion accompanied by the production of distal symptoms can also occur.165 Side bending toward or away from the side of the pain can also reproduce upper extremity symptoms, depending on the cause. Pain caused by intervertebral foraminal narrowing may be increased with ipsilateral side bending. Pain caused by an IVD protrusion may be increased with contralateral side bending.

A restriction of the opposite motions (cervical flexion, side bending, and rotation to the opposite side of the pain) is termed an opening restriction. Opening restrictions are slightly more difficult to identify in the cervical spine because, frequently, there is no actual restriction of cervical flexion, but rather a restriction of rotation and side bending, along with reproduction of pain on the contralateral side.165

McKenzie117 advocates using neck retraction and protrusion, with other motions and positions being superimposed. Neck protrusion produces an extension of the upper cervical spine and flexion of the mid and lower cervical spine, whereas neck retraction produces a flexion of the upper cervical spine and an extension of the mid and lower cervical spine. Neck retraction is performed with extension (Fig. 25-14), side bending (Fig. 25-15), and rotation to both sides in sitting position and then prone, with the head off the end of the table (Figs. 25-16 and 25-17). The results from these motions are combined with the findings from the history and the single-plane motions to categorize the symptomatic responses into one of three syndromes: postural, dysfunction, or derangement. This information can guide the clinician as to which motions to use in the intervention.

Key Muscle Testing

The purpose of resisted testing is outlined in Chapters 3 and 4. There are numerous smaller muscles throughout this area, so resistance needs to be applied gradually. The same movements that were done actively are tested isometrically. Some of these muscles are also tested as part of the Cyriax upper quarter scanning examination (see Chap. 4) and are used as a peripheral joint scanning examination to determine muscle power and possible neurological weakness. Ideally, the clinician should place the joint in its resting position before testing each muscle and the contraction should be held for at least 5 seconds.

Resisted Cervical Flexion

Resisted cervical flexion tests the key muscle of C1–2, and cranial nerve XI (spinal accessory).

Resisted Cervical Rotation

Resisted cervical rotation (Fig. 25-18) tests the key muscle of C2.

Resisted Cervical Side Bending

Resisted side bending tests the key muscle of C3, and cranial nerve XI (Fig. 25-19).

Scapular Elevators (C4 and Cranial Nerve XI)

The clinician asks the patient to elevate the shoulders about one-half of full elevation. The clinician applies a downward force on both shoulders, while the patient resists (Fig. 25-20).

Diaphragm (C4)

Using a tape measure, the clinician measures the amount of rib expansion that occurs with a deep breath (Fig. 25-21). A comparison is made to a similar measurement at rest. Four measurement positions are used:

1. fourth lateral intercostal space;

2. axilla;

3. nipple line;

4. tenth rib.

Shoulder Abduction (C5)

The clinician asks the patient to abduct the arms to about 80–90 degrees, with the forearms in neutral. The clinician applies a downward force on the humerus, while the patient resists (Fig. 25-22).

Shoulder External Rotation (C5)

The clinician asks the patient to put the arms by the sides, with the elbows flexed to 90 degrees and the forearms in neutral. The clinician applies an inward force to the forearms (Fig. 25-23).

Elbow Flexion (C6)

The clinician asks the patient to position the arms, with the elbows flexed to 90 degrees and the forearms supinated. The clinician applies a downward force to the forearms (Fig. 25-24).

Wrist Extension (C6)

The clinician asks the patient to place the arms by the sides, with the elbows flexed to 90 degrees and the forearms, wrists, and fingers in neutral. The clinician applies a downward force to the back of the patient's hands (Fig. 25-25).

Shoulder Internal Rotation (C6)

The clinician asks the patient to put the arms by the sides, with the elbows flexed to 90 degrees and the forearms in neutral. The clinician applies an outward force to the forearms (Fig. 25-26).

Elbow Extension (C7)

The patient is seated with the arm above the head and the elbow flexed. The clinician stands beside the patient and tests the triceps by grasping the patient's forearm and attempting to flex the elbow (Fig. 25-27).

Wrist Flexion (C7)

The clinician asks the patient to place the arms out in front, with the elbows flexed slightly and the forearms, wrists, and fingers in neutral. The clinician applies an upward force to the palm of the patient's hands (Fig. 25-28).

Thumb Extension (C8)

The patient extends the thumb just short of full range of motion. The clinician stabilizes the patient's wrist with one hand and applies an isometric force into thumb flexion with the other (Fig. 25-29).

Hand Intrinsics (T1)

The patient is asked to squeeze the clinician's fingers between their fingers, while the clinician tries to pull their fingers away (Fig. 25-30).

Based on the findings from the history, systems review, and key muscle testing, a sensory examination may be necessary (see Chap. 3).

Strength Testing of the Deep Segmental and Postural Support Muscles

Deep Neck Flexors

The patient is positioned in supine, with the knees bent and the feet flat on the bed. The patient's head and neck are positioned in the desired midrange neutral position of the craniocervical region—where the line of the forehead and chin is in a horizontal plane and an imaginary line extending from the tragus and bisecting the neck longitudinally is parallel to the bed. If the patient does not adopt this position automatically, padding may be used. Once the correct position is obtained, an inflatable pressure sensor (Stabilizer, Chattanooga, South Pacific) is folded in three and positioned suboccipitally behind the neck (Fig. 25-31), such that it abuts the occiput. The bladder is inflated until the pressure is stabilized on the baseline of 20 mm Hg, a volume sufficient to just fill the space between the bed and the patient's neck, without exerting any pressure on the neck. The patient is instructed to gently nod the head slowly in an arc-like motion as if saying “yes,” while the clinician notes both the quality and the quantity of motion. Ideally, there should be a pattern of progressively increasing craniocervical flexion (Table 25-11). With weak deep neck flexors in the presence of a strong SCM, the jaw juts forward at the beginning of the movement, producing hyperextension of the craniovertebral junction85 (Fig. 25-32). Confirmation is made by applying a very slight amount of resistance (2–4 g) against the patient's forehead.

Holding Capacity of Deep Segmental and Postural Support Muscles68

This test is designed to assess the ability of a muscle group to sustain a low-load isometric contraction and to replicate its function.

Deep Neck Flexors

The deep flexors of the craniovertebral and cervical regions are assessed by testing the patient's ability to sustain a precise inner range upper cervical flexion action.68

The patient is positioned in supine, with the head being supported on a folded towel, the knees flexed, and the feet flat on the bed. The inflatable pressure sensor is again positioned suboccipitally behind the neck (Fig. 25-31), and the bladder is inflated to 22 mm Hg to just fill the space between the bed and the patient's neck, without exerting any pressure on the neck.

The patient is asked to bring the chin toward the sternum in a gentle and slow manner. Ideally, the patient should attempt to target five incremental pressure targets (in increments of 2 mm Hg) from the baseline level of 22 mm Hg.68

Lower Scapular Stabilizers

The mid and lower trapezius, and serratus anterior muscles, can be assessed with the patient positioned in prone, the arm slightly abducted, and the arms placed by the side of the patient. The patient is asked to sustain the scapula against the chest wall in a position of retraction and depression (Fig. 25-33), while the clinician palpates over the muscles.68 The end-range position is sustained for 10 seconds, and the test is repeated 10 times.

Retraining the postural support muscles initially involves postural education, an emphasis on the relaxation of unwanted muscle activity, and repeated repetitions of 10-second holds of the corrected scapula position.

Muscle Length Testing

Upper Trapezius

The upper trapezius has a tendency to become adaptively shortened and overactive, which can have the effect of pulling the head laterally, as well as increasing the craniovertebral and cervical lordosis.166

The patient is positioned in supine. The patient's head is maximally flexed, inclined to the contralateral side (Fig. 25-34), and ipsilaterally rotated. While stabilizing the head, the clinician depresses the shoulder distally. A normal finding is free movement of about 45 degrees of rotation, with a soft motion barrier. Tightness of this muscle results in a restriction in the range of motion and a hard barrier.

Levator Scapulae

A quick test to determine the extensibility of the levator involves positioning the patient sitting.165 The patient is asked to place one hand above the head. For example, the right hand if the length of the right levator is to be tested, the patient's neck and head are positioned in left side flexion, and the patient is asked to abduct the left arm as far as possible. Normal extensibility of the levator and the rhomboids, and the absence of shoulder girdle pathology, should allow the patient to fully abduct the arm, while the head is side bent away (Fig. 25-35). The test is repeated on the other side for comparison.

The more specific test involves positioning the patient in supine. The clinician maximally flexes the patient's head, induces contralateral rotation, and inclines the head toward the contralateral side (Fig. 25-36). The clinician then depresses the patient's shoulder distally. If tightness is present, there will be tenderness at the levator insertion and a restriction of movement to less than 45 degrees.

Sternocleidomastoid

The SCM muscle has a tendency to become adaptively shortened and overactive, which can have the effect of altering the relationships between the head, neck, and shoulders and producing restrictions at the craniovertebral and cervicothoracic junctions.166

The patient is positioned in supine, with the head being supported. From this position, the clinician induces side bending of the neck to the contralateral side and extension of the neck (Fig. 25-37). The clinician stabilizes the scapula and rotates the patient's head and neck toward the ipsilateral side.

Scalenes

The patient is positioned in supine, with the clinician at the head of the bed. The clinician side flexes and extends the head to the contralateral side, while stabilizing the shoulder (Fig. 25-38). The normal range of motion should be 45 degrees.

Neurologic Examination

The neurologic examination is performed to assess the normal conduction of the central and peripheral nervous systems and to help rule out such conditions as brachial neuritis and TOS. The tests for the TOS are described under “Special Tests” section later. Depending on the results from the history, a cranial nerve examination may be warranted (see Chap. 3).

Sensory (Afferent System)

The clinician instructs the patient to say “yes” each time he or she feels something touching the skin. The clinician notes any hypoesthesia or hyperesthesia within the spinal and peripheral nerve distributions. Light touch of hair follicles is used throughout the whole dermatome, followed by pinprick in the area of hypoesthesia. Remember that there is normally no C1 dermatome!

Muscle Stretch Reflexes

The following muscle stretch reflexes should be checked for differences between the two sides:

• C5–6: brachioradialis (Fig. 25-39)
• C6: biceps (Fig. 25-40)
• C7: triceps (Fig. 25-41)

Pathological Reflexes

The following reflexes are tested:

• Hoffmann's sign (Fig. 3-36)
• Babinski (Fig. 3-29)
• Lower limb deep tendon reflexes (Achilles and patellar) for hyperreflexia

Palpation

The results from palpation rely on the patient's subjective report; thus, changes in the patient's attention and pain tolerance affect reliability. It is important to place the patient in a position where the neck muscles can relax. Usually, this involves the patient lying supine with their head supported by a pillow and the clinician positioned at the patient's head.

In the neck, the major lymph nodes are located along the anterior and posterior aspects of the neck, which is divided by the SCM muscle.131 Usually, the closer the lymph node is to the spinal cord, the greater the size of the lymph node.131 The neck is the exception to the rule. Other lymph nodes are also located on the underside of the jaw and suboccipital areas.131 The number and size of lymph nodes usually decrease with aging.

The anterior neck can be palpated for the thyroid gland by gently displacing the trachea laterally and palpating each side in turn. Asking the patient to swallow during the palpation can help locate the thyroid gland, as it should be felt to slide under the fingers while it moves upward.

Using the index fingers, the clinician slides the fingers under the SCM and begins to palpate the anterior aspect of the cervical vertebral bodies (from C7 to C3) for tenderness. The posterior aspects, including the facet joints, can be palpated with the other hand. If palpation reveals some tenderness, the clinician can further stress the segment by gently applying a posteroanterior pressure.167 This is accomplished using the hand under the neck and applying an anterior shear at each segmental level. This pressure should result in a slight increase in the cervical lordosis. If it results in an excessive anterior glide at the segment compared with the segment above or below, the test can be considered positive and a stability test of that segment should be performed.

According to Hoppenfeld,169 all of the spinous processes lower than C2 are usually palpable. The interval between the external occipital protuberance and the spine of C2 contains the posterior arch of vertebra C1, which is very deeply located and usually not palpable. The C2 spinous process can be palpated in the midline below the external occipital protuberance, the prominent midline elevation on the posteroinferior aspect of the occipital bone.1 Occasionally, because of a bifid spine that is not symmetric, the spine may appear to be lateral to the midline, or two bony prominences may be felt at a single level between C3 and C6. C7 is usually the longest spinous process, being referred to as the vertebra prominens, although the spinous process of either C6 or T1 might be quite long, as well. The spinous process of C7 is located by either counting down to the correct level or using a motion test. The motion test involves the clinician feeling for the largest spinous process located at the base of the neck and then asking the patient to extend the neck. The C6 spinous process will be felt to move anteriorly with neck extension, whereas the spinous process of C7 does not.

The following muscles should be palpated for tenderness:

• trapezius;
• sternocleidomastoid;
• splenius;
• semispinalis;
• multifidus;
• suboccipitals (see Chap. 23).

The TMJ can be checked for clicking, limited range of motion, tenderness, or swelling by gently palpating the area immediately anterior of the tragus of each ear while the patient slowly opens and closes the mouth (see Chap. 26).131

Differing Philosophies

The next stage in the examination process depends on the clinician's background. Many manual techniques are used to examine the cervical spine, but the reproducibility of these techniques is questionable.171–175 Clinicians who are heavily influenced by the muscle energy techniques of the osteopaths176 use position testing to determine the segment on which to focus. Other clinicians omit the position tests and proceed to the combined motion and passive physiologic tests.

Position Testing

The position tests are screening tests that, like all screening tests, are valuable in focusing the attention of the clinician on one segment, but not appropriate for making a definitive statement concerning the movement status of the segment. However, when combined with the results of the active and passive movement testing, they help to form a working hypothesis.

The patient is positioned sitting, and the clinician stands behind the patient. Using the thumbs, the clinician palpates the articular pillars of the cranial vertebra of the segment to be tested (Fig. 25-42). The patient is asked to flex the neck, and the clinician assesses the position of the cranial vertebra relative to its caudal neighbor and notes which articular pillar of the cranial vertebra is the most posterior (dorsal). A posterior (dorsal) left articular pillar of the cranial vertebra relative to the caudal vertebra is indicative of a left-rotated position of the segment in flexion.176

In the following example, the C4 and C5 segments are used. The patient is asked to extend the joint complex, while the clinician assesses the position of the C4 vertebra relative to C5 by noting which articular pillar is the most posterior (dorsal). A posterior (dorsal) left articular pillar of C4 relative to C5 is indicative of a left-rotated position of the C4–5 joint complex in extension.176

This test may also be performed with the patient supine. However, in the sitting position, one can better observe the effect of the weight of the head on the joint mechanics.

Passive Physiologic Intervertebral Mobility Testing

These screening tests examine intersegmental mobility. As with any other screening test, these tests quickly obviate the need for more exhaustive testing and focus the clinician's attention on a specific level or levels and specific movement(s). Manual examination of the cervical spine by experienced clinicians has shown good sensitivity and specificity to detect cervical zygapophyseal syndromes compared with other medical diagnostic tools, including radiographs, and are sensitive for identifying fused joint levels (Table 25-12).98,177 However, the protocols used to assess general mobility and intersegmental mobility of the cervical spine have demonstrated difficulty achieving reasonable interexaminer agreement and reliability.172,175

To test the intersegmental mobility of the midcervical region, the patient is positioned in supine and the the patient's neck is placed in the neutral position of the head on the neck, and the neck on the trunk. Once in this position, lateral glides are performed, beginning at C2 and progressing inferiorly. The lateral glides are usually tested in one direction before repeating the process on the other side. The lateral glides result in a relative side bending of the cervical spine in the direction opposite to the glide. Light pressure from the clinician's body can be applied against the top of the patient's skull to hold the head in position. This reinforces the stabilization caused by the weight of the patient's thorax against the table. Each spinal level is glided laterally to the left and right, while the clinician palpates for muscle guarding, range of motion, end-feel, and the provocation of symptoms. Lateral glides are performed as far inferiorly as possible.

Following these procedures, the areas in which a restricted glide was found are targeted, and repetition of the lateral glides is performed in the flexed and then extended positions.

Flexion

The same considerations are pertinent for flexion hypomobilities. To test in flexion, the patient's head and neck are flexed without allowing a chin tuck, which would tighten the nuchal ligament (Fig. 25-43). For example, if left side bending is restricted in flexion, the right side of the segment is not flexing sufficiently (see Table 25-8). The opposite occurs if the restriction occurs with right-side bending (the left side is not flexing sufficiently).

Extension

With the patient supine, and the occiput cupped, the segment is extended by lifting the superior vertebra forward (obviating the need to extend the entire spinal region) and allowing the patient's head and neck to bend over the fulcrum, created by the clinician's fingers. While maintaining the extended position (by pushing the transverse processes of the segment anteriorly), the segment is side bent left and then right around its axis of motion and translated contralaterally (Fig. 25-44). During the translation, very slight head motion should occur. Rather, a slight tilting around each segmental axis occurs, using gentle pressure via the fingertips or the fleshy part of the second metacarpophalangeal joint. The slight side bending before the translation is to fix the axis at that segmental level. During left side bending, the left side of the segment is maximally extended, while the right side is moved toward its neutral position. The opposite occurs with right side bending.

The range of motion of the side bending and the end-feel of the translation is evaluated for normal, excessive, or reduced motion states. If the end-feel of the translation is normal, but the side bending is restricted, the hypomobility is extra-articular (myofascial) (see Table 25-8).

To test the intersegmental mobility of the lower cervical/upper thoracic region, the patient is positioned in side lying with their arm over the end of the table to stabilize the thorax and their head cradled by the clinician (Fig. 25-45). The patient's neck is placed in the neutral position of the head on the neck and the neck on the trunk. Once in this position, the clinician uses the index finger to monitor intersegment motion between the spinous processes, while passively moving the patient's head and neck into flexion, extension, side bending, and then rotation.

Because of the unreliability of mobility testing in extension, the information gleaned from motion testing is more likely to be more reliable in determining the side of the closing restriction.

Clinically, it would appear that the zygapophyseal joints are more involved with the rotational aspect of the coupling, functioning to prevent excessive rotation, whereas the uncovertebral joints appear to be more involved with pure side-bending motions. Although this concept may not hold up to scientific scrutiny, it tends to work well in the clinic. Thus, a glide restriction found in flexion, extension, and neutral would tend to implicate a problem with the uncovertebral joint.

While it is not necessary, or sometimes not possible, to make a diagnosis from these tests, some useful deductions can be made and these will direct the ensuing joint glide tests to the appropriate joint. Remember, that if the end-feel of the glide suggests that motion is still occurring at the end of available range, the joint is not the cause of restriction (think muscle).

Passive Physiologic Accessory Intervertebral Mobility Tests

The passive physiologic accessory intervertebral mobility (PPAIVM) tests investigate the degree of linear or accessory glide that a joint possesses and are used on segmental levels where there is a possible hypomobility, to help determine if the motion restriction is articular, periarticular, or myofascial in origin. In other words, they assess the amount of arthrokinematic motion, as well as the quality of the end-feel. The motion is assessed in relation to the patient's body type and age and the normal range for that segment, and the end-feel is assessed. A variety of techniques can be used to assess the joint glides in this region. Unless otherwise stated, the patient is positioned in supine with their head resting on the treatment table. The cervical spine is positioned in midrange in relation to flexion, extension, side bending, and rotation. The clinician is positioned at the patient's head. For each of the tests, the clinician assesses the quantity and quality of motion and makes comparisons to the contralateral side, or to the adjacent segment, as appropriate.

Distraction

Using both hands, the clinician wraps around the occiput of the patient using the web space of the hands. The clinician leans backward, and gently applies a force to the chin and occiput to distract the vertebral bodies from one another (Fig. 25-46). Most of the force should be directed to the occiput.

Segmental Translation

In the following example, a left side bending of C3–4 will be described. The patient is positioned in supine, with the clinician at the head of the bed. The clinician cradles the patient's head with both hands and places the pad of the index fingers of each hand across the neural arches of C3. The clinician then applies a right translatory (shearing) force on the C3 neural arch, while keeping the head and upper neck in neutral. A firm end-feel should be achieved as the soft tissue slack is taken up in the joints below as, at the C3–4 level, there is a normal congruent set of motions occurring, e.g., left side bending/rotation with right translation (Fig. 25-47). However, at the levels below there is an incongruent set of motions occurring, e.g., right side bending/rotation with right translation. The diagnostic accuracy for these tests are unknown, but the reliability scores from one study175 were kappa = 0.03–0.63 (mobility) and ICC = 0.22–0.80 (pain).

Rotation

To test the motions involved with cervical rotation, the patient is positioned in supine and the cervical spine is placed in the range in relation to flexion, extension, side bending, and rotation. The clinician stands at the patient's head. Leaning forward, the clinician rests the abdomen against the top of the patient's head. Using one hand, the clinician grips the inferior segment posteriorly using the web space of the hand, and laterally with the index finger and thumb. Using a similar grip, the clinician uses the other hand to wrap around the superior segment. While stabilizing the inferior segment, the clinician glides the superior segment into rotation (Fig. 25-48).

Combined Motions

Leaning forward, the clinician rests the abdomen against the top of the patient's head. Using one hand, the clinician grips the inferior segment posteriorly using the web space, and laterally with the index finger and thumb. Using a similar grip, the clinician uses the other hand to wrap around the superior segment. The patient's head is then guided into the four quadrants: flexion and rotation to the right (Fig. 25-49), flexion and rotation to the left, extension and rotation to the right, and extension and rotation to the left.

Cervical Stress Tests

Depending on the irritability of the segment, a variety of tests can be used to assess for instability. It is worthwhile to start gently with segmental palpation and gentle posteroanterior pressures before progressing to the other techniques. Unless indicated, the patient is positioned supine. The following tests are performed to examine segmental stability.

Posteroanterior Spring Test

The patient is positioned in prone for anterior stability testing; the clinician places his or her thumbs over the posterior aspects of the transverse processes of the inferior vertebra of the segment being tested. To ensure patient comfort during this test, the thumbs must be placed under (posterior to) the SCM, rather than over it, and must function merely to stabilize the maneuver, exerting no pushing force. The vertebra is then pushed anteriorly (Fig. 25-50), and the clinician feels for the quality and quantity of movement. A rotational component can be added to the test by applying force on only one of the transverse processes.

For posterior stability testing, the thumbs are placed on the anterior aspect of the superior vertebra, and the index fingers are on the posterior aspect (neural arch) of the inferior.167 The inferior vertebra is then pushed anteriorly on the superior one, producing a relative posterior shear of the superior segment.

It is likely that this test is highly sensitive at implicating the dysfunctional level, but is not specific for the causative pathological process. However, the diagnostic value of this test is as yet unknown.

Transverse Shear

The transverse shear test should not be confused with the lateral glide tests previously mentioned. The lateral glide tests are used to assess joint motion, whereas the transverse shear test assesses the stability of the segment. Although motion is expected to occur in the lateral glide test, no motion should be felt to occur with the transverse shear test.178

The inferior segment is stabilized, and the clinician attempts to translate the superior segment transversely using the soft part of the metacarpophalangeal joint of the index finger167 (Fig. 25-51). The end-feel should be a combination of capsular and slightly springy. The test is then reversed so that the superior segment is stabilized and the inferior segment is translated under it.

The test is repeated at each segmental level and for each side. The diagnostic value of this test is as yet unknown.

Craniovertebral Ligament Stress Tests

The tests for these ligaments, which include the alar and transverse ligament, are described in Chapter 23.

Distraction and Compression

The patient is supine, and the clinician sits or stands at the patient's head. The clinician cups the patient's occiput in one hand and rests the anterior aspect of the ipsilateral shoulder on the patient's forehead. The other hand stabilizes at a level close to the base of the neck167 (Fig. 25-46). A traction–compression–traction force is applied. This test can also be performed with the patient in sitting (Figs. 25-52 and 25-53). The clinician notes the quality and quantity of motion.

Pain reproduced with compression suggests the presence of

• disk herniation;
• vertebral end plate fracture;
• vertebral body fracture;
• acute arthritis or joint inflammation of a zygapophyseal joint;
• nerve root irritation, if radicular pain is produced.

Reproduction of pain with cervical distraction suggests the presence of

• spinal ligament tear;
• tear or inflammation of the AF;
• muscle spasm;
• large disk herniation;
• dural irritability (if nonradicular arm or leg pain is produced).

Functional Assessment

A number of formal ways of measuring neck function are available, and include the following:

• The neck disability index (NDI) is a patient survey instrument (see Table 5-3) that contains 10 items, seven related to activities of daily living, two related to pain, and one item related to concentration. The NDI is a revision of the Oswestry index and is designed to measure the level of reduction in activities of daily living in patients with neck pain. The NDI has been widely researched and validated,179 and its test–retest reliability has been found to be 0.89.179
• The Northwick Park Neck Pain Questionnaire (Table 25-13)180 contains nine sections that cover activities likely to affect neck pain. Each section contains five statements related to the patient's perceived level of difficulty performing the activity of the section. Scores on the questionnaire range from 0 to 100%, with 0% being associated with no disability and 100% with severe disability. The questionnaire has good short-term repeatability and internal consistency.181

Special Tests

In most cases, the special tests are only performed if there is some indication that they would be helpful in arriving at a diagnosis. However, in the cervical spine, in addition to the cervical stress tests, the vertebral artery should also be assessed (see Chap. 24), especially if the plan is to place the cervical spine in the extremes of extension, or extension and rotation as part of the examination or treatment.

Temporomandibular Joint Screen

Because the TMJ (see Chap. 26) can refer pain to this region, the clinician is well advised to rule out this joint as the cause for the patient's symptoms.

The patient is asked to open and close the mouth and to laterally deviate the jaw, as the clinician observes the quality and quantity of motion and notes any reproduction of symptoms.

Neurodynamic Mobility Tests

Upper limb tension testing (see Chap. 11) may serve a useful role in differentiating between the involvement of neural and nonneural structures.8

Lhermitte's Symptom or “Phenomenon”

This is not so much a test as it is a symptom, described as an electric shock-like sensation that radiates down the spinal column into the upper or lower limbs when flexing the neck (see Chap. 3).

Flexion Rotation Test

This test is used to determine the presence of a cervicogenic headache and is both a range of motion and provocation test. The patient is positioned in supine and resting symptoms are noted. The patient is asked to maximally flex his or her neck and to hold that position. Using both hands, the clinician applies a full rotational force to both sides and notes any changes in symptoms (Fig. 25-54). The test is considerd positive for a cervicogenic headache if a loss of 10 degrees or greater is noted when comparing both sides. Given the testing position, it is likely that C1–2 is the tested level. A single blind, age and gender matched, comparative measurement study by Hall and Robinson182 found this test to have a sensitivity of 86% and a specificity of 100% (QUADAS score of 12).

Scalene Cramp and Relief Tests

For the scalene cramp test, the patient is positioned in sitting and is asked to turn the head toward the painful side and pull the chin down into the supraclavicular fossa (Fig. 25-55). This position causes contraction of the scalenes and should reproduce distal radiation of pain if the scalenes are involved. The scalene relief test is performed by asking the patient to actively place the forearm against the forehead on the involved side. This position increases the space between the clavicle and the scalenes and is positive for scalene dysfunction if it relieves the patient's pain. No diagnostic accuracy studies have been performed to determine the sensitivity and specificity of this test.

Spurling Test

Provocative tests for cervical radiculopathy include the foraminal compression test or Spurling test.183 The patient is positioned in sitting. The test is performed by asking the patient to rotate the head to the uninvolved side and then the involved side (Fig. 25-56). The clinician then carefully applies a downward pressure on the head, with the head in neutral. The test is considered positive if pain radiates into the limb ipsilateral to the side at which the head is rotated.184 Neck pain with no radiation into the shoulder or arm does not constitute a positive test. Conditions such as stenosis, cervical spondylosis, osteophytes, or disk herniation are implicated with a positive test. There are few methodologically sound studies that assess the interexaminer reliability, sensitivity, and specificity of this test. The literature appears to indicate high specificity and low sensitivity.185 Therefore, the test is not useful as a screening test, but it is clinically useful in helping to confirm a cervical radiculopathy.

Modifications to this test have been advocated, which divide the test into three stages, each of which is more provocative.120 If symptoms are reproduced, the clinician does not progress to the next stage. The first stage involves applying compression to the head in neutral. The second stage involves compression with the head in extension. The final stage involves compression with the head in extension and rotation to the uninvolved side, and then to the involved side. No diagnostic accuracy studies have been performed to determine the sensitivity and specificity of these variations.

Valsalva

The patient is positioned in sitting and is instructed to hold his or her breath and then “bear down” as in performing a bowel movement. Reproduction of the consistent pain during bearing down is considered a positive response for a disk herniation (Table 25-14).

Shoulder Abduction Test

This test186,187 is used to test for the presence of radicular symptoms. The patient is positioned sitting or supine and is asked to elevate the arm through abduction, so that the hand or forearm rests on top of the head (Fig. 25-57). If this position relieves or decreases the patient's symptoms, a cervical extradural compression problem, such as a herniated disk, or nerve root compression should be suspected. The literature seems to indicate high specificity with low sensitivity for this test (Table 25-14). The specific segmental level can be determined by the dermatome distribution of the symptoms. If the symptoms are increased with this maneuver, the implication is that pressure is increasing in the interscalene triangle.187

Brachial Plexus Compression Test

The patient is positioned in sitting and is asked to side bend the head to the uninvolved side. The clinician applies firm pressure to the brachial plexus by squeezing the plexus lateral to the scalenus between the thumb and fingers (Fig. 25-58). Reproduction of shoulder or upper arm pain is positive for mechanical cervical lesions (Table 25-14), or a thoracic outlet dysfunction.188

Cervical Hyperflexion

The patient is positioned in sitting and is asked to flex his or her neck to the first point of pain or toward end range if no pain exists (Fig. 25-59). Reproduction of radicular symptoms during hyperflexion is considered a positive response (Table 25-14).

Cervical Hyperextension (Jackson's Test)

The patient is positioned in sitting and is asked to extend his or her neck to the first point of pain or toward the end range if no pain exists (Fig. 25-60). Reproduction of symptoms is considered a positive response (Table 25-14).

Cervical Distraction

The patient is positioned in supine. Using one hand the clinician uses a lumbrical grip around the occiput. Using the other hand the clinician wraps the hand gently around the patient's chin. A traction force is applied and the patient's symptoms are assessed (Fig. 25-61). A positive test is reduction of symptoms during traction and is indicative of some form of foraminal compression, or zygapophyseal joint irritation. This test appears to have high specificity but low sensitivity (Table 25-14).

Brachial Plexus Tests

Stretch Test

The patient is positioned sitting or standing and is asked to raise the arm on the involved side (Fig. 25-62) and then to side bend the head to the uninvolved side. Pain and paresthesia along the involved arm are indicative of a brachial plexus irritation.

Cervical Rotation Lateral Flexion Test

This test is used as part of the examination of a patient presenting with brachialgia and thoracic outlet symptoms to assess first rib hypomobility. The motion of cervical rotation combined with lateral flexion (side bending) can be restricted in the presence of a subluxed first rib at the costotransverse joint.189 The patient is seated and the cervical spine positioned in neutral with regard to flexion–extension. The clinician then passively rotates the cervical spine maximally, away from the side to be tested, and then flexes the neck forward as far as possible, moving the ear toward the chest (Fig. 25-63). The test is then repeated to the other side, and a comparison is made about the quantity and quality of motion. If the first rib is subluxed, the restriction to passive movement is felt abruptly. If restricted motion is found on one side, first-rib mobilizations are performed and then the patient is retested. Lindgren and colleagues found this test to have excellent interobserver repeatability and to have good agreement with a radiologic examination in the detection of a subluxed first rib.190 However it is worth remembering that a number of additional factors may influence the finding, including TOS, cervical radiculopathy, and upper thoracic pain.

Tinel's Sign

The patient is positioned in sitting and is asked to side bend the head to the uninvolved side. The clinician taps or squeezes along the trunks of the brachial plexus using the fingers (Fig. 25-64). Local pain indicates a cervical plexus lesion. A tingling sensation in the distribution of one of the trunks may indicate a compression or neuroma of one or more trunks of the brachial plexus.191

Thoracic Outlet Tests

Despite their widespread use, no studies documenting the reliability of the common thoracic outlet maneuvers of Adson's, Allen's, or the costoclavicular maneuver have been performed.192 Because TOS is a controversial diagnosis, most of the thoracic outlet tests examine specificity only.

When performing TOS tests, either the diminution or disappearance of pulse or reproduction of neurologic symptoms indicates a positive test. However, the aim of the tests should be to reproduce the patient's symptoms rather than to just obliterate the radial pulse.

Adson's Vascular Test

The patient is positioned in sitting with the arms placed at 15 degrees of abduction. The clinician palpates the radial pulse. The patient is asked to inhale deeply, and to hold his or her breath (Fig. 25-65). The patient is then asked to tilt the head back, and rotate the head, so that the chin is elevated and pointed towards the examined side. The clinician records the radial pulse as diminished or occluded and asks the patient about the presence of paresthesia. The test position theoretically increases the scalenus angle and the tension of the anterior and middle scalenes thereby compromising the interscalene triangle.193 However, biomechanically, the scalene angle actually increases, which should reduce the likelihood of compression. Moreover, to date, no studies have been performed to document the reliability of this test. Plewa and Delinger194 found the specificity of this test to be 100% when assessing pain, 89% when assessing vascular changes, and 89% when assessing paresthesia.

Costoclavicular Test

The patient is positioned sitting straight in an exaggerated military posture and with both arms at the sides. The clinician assesses the radial pulse in this position. The patient is asked to retract and depress the shoulders while protruding the chest (Fig. 25-66). This position is held for 60 seconds. The clinician assesses changes in the radial pulse and asks the patient about the presence of paresthesia. It is likely that this test position reduces the volume of the costoclavicular space. Plewa and Delinger194 found the specificity of this test to be 100% when assessing pain, 89% when assessing vascular changes, and 85% when assessing paresthesia.

Roos Test195

The patient is positioned sitting. The arm is positioned in 90 degrees of shoulder abduction, and 90 degrees of elbow flexion. The patient is asked to perform slow finger clenching for 3 minutes (Fig. 25-67). The radial pulse may be reduced or obliterated during this maneuver, and an infraclavicular bruit may be heard. If the patient is unable to maintain the arms in the start position for 3 minutes, or reports pain, heaviness, or numbness and tingling, the test is considered positive for TOS on the involved side. This test is also referred to as the hands-up test, or the elevated arm stress test. No diagnostic accuracy studies have been performed to determine the sensitivity and specificity of this test.

Hyperabduction Maneuver (Wright Test).196

The patient is positioned in relaxed sitting. The clinician palpates the radial pulse and then asks the patient to hyperabduct his or her shoulders and to turn the head away from the side being examined (Fig. 25-68). The position is held for 1–2 minutes. A positive test includes reproduction of paresthesia or a decrease in the radial pulse. No diagnostic accuracy studies have been performed to determine the sensitivity and specificity of this test. However, is important to note that a number of studies have found that arm elevation induces radial pulse obliteration in 60–69% of normal subjects.197,198

Passive Shoulder Shrug

This simple, but effective, test is used with patients who present with symptoms of TOS to help rule out this syndrome. The patient is seated with the arms folded, and the clinician stands behind. The clinician grasps the patient's elbows and passively elevates the shoulders up and forward (Fig. 25-69). This position is maintained for 30 seconds. Any changes in the patient's symptoms are noted. The maneuver has the effect of slackening the soft tissues and the brachial plexus. No diagnostic accuracy studies have been performed to determine the sensitivity and specificity of this test.

The reader is encouraged to refer to Chapter 11 for the descriptions of these tests. The upper limb tension tests are equivalent to the straight leg raise test and others of the lower extremities and are designed to put stress on the neuromeningeal structures of the upper limb. A negative finding strongly suggests a lack of existence of radiculopathy (Table 25-15). Each test begins by testing the normal side first. Normal responses include

• deep stretch or ache in the cubital fossa;
• deep stretch or ache into the anterior or radial aspect of the forearm and radial aspect of hand;
• deep stretch in the anterior shoulder area;
• sensation felt down the radial aspect of the forearm;
• sensation felt in the median distribution of the hand.

Positive findings include

• reproduction of the patient's symptoms;
• a sensitizing test in the ipsilateral quadrant that alters the symptoms.

It is recommended that the results of any imaging studies should be viewed after the clinical examination, so as to remove the potential for bias, especially in light of the fact that degenerative changes and anatomical variations are fairly common in the cervical spine, but that many of these changes have no relationship to the patient's complaints. A description of the various imaging studies and their relevance to a specific region are described in Chapter 7.

Cervical impairments have the same causes as any other areas of the body, that is, a micro- or macrotraumatic impairment of the structures that compose the joint complex.

The clinician must discuss the diagnosis, prognosis, and the intervention with the patient. It is important that the clinician describe the basic anatomy and function of the cervical spine in a way that the patient will understand. Expectations of both the patient and the clinician must be clarified. Patients must realize at the outset that they are responsible for their own recovery and must participate actively in their treatment.

Based on a working hypothesis, the physical therapy intervention needs to be precise, and guided by the impairments, functional limitations, and disability found during the examination. The intervention should aim to reverse the dysfunction and to prevent the recurrence of future episodes. A study by Saturno and colleagues,199 which assessed the reliability and validity of existing clinical guidelines on neck physiotherapy treatment and follow-up in Spain, determined the eight evidence-based recommendations listed in Table 25-16. Other studies have reported that physical therapy interventions that have included manual therapy, postural reeducation, neck-specific strengthening and stretching exercises, and ergonomic changes at work have been shown to be beneficial in reducing neck pain and improving mobility.200–202 A pragmatic randomized clinical trial by Hoving et al.,203 that compared the effectiveness of manual therapy (mainly spinal mobilizations), physical therapy (mainly exercise therapy), and continued care by the general practitioner (analgesics, counseling, and education) for cervical pain over a period of 1 year, found high improvement scores for the manual therapy group for all of the outcomes, followed by physical therapy and general practitioner care.

The joint mobilization techniques for the cervical spine and the manual techniques to increase soft tissue extensibility are described later, under “Therapeutic Techniques” section.

Systematic reviews of physical therapy modalities for neck pain report a lack of high-quality evidence of their efficacy and highlight poor methodologic quality in many studies.204 Electrotherapy has a long history of use in physical therapy interventions and two high-quality trials reported that pulsed shortwave diathermy delivered by small portable units inserted into cervical collars significantly reduced pain in patients with mechanical neck pain.205,206

Acute Phase

During the acute phase, the patient should be encouraged to perform as many activities of daily living as possible. The return to activities should be encouraged and begin within 2–4 days after a cervical injury, depending on severity. Rest is usually advocated in the first 24–72 hours, depending on the severity of the injury, to give healing a chance. Indications for rest include pain reported with all neck and head motions, however, slight, and high irritability of the symptoms. Ignoring the need for rest in these situations increases the risk of delaying the recovery from the acute phase. In those situations where absolute rest is warranted, the patient is told that rest means just that. Pillows should be adjusted so that the head remains in neutral when sleeping in side-lying or supine position. The patient should be cautioned about prone lying.

Patients are encouraged to take up or resume a regular activity such as walking or, later in this phase, swimming and perhaps running, or anything else that will get them back to a normal mind set about their function, without reinjuring the area.

In general, two basic approaches are used to treat neck pain with exercises:

• General strengthening and endurance exercises for the neck flexor muscles.207,208
• Specific exercises designed to improve coordination and control of the muscles.78

Appropriate exercises must ensure proper motor control, performance, and endurance of a specific part of the body. When prescribing exercises to the patient, the clinician must decide on the type of muscle contraction, the patient's body position, the level of resistance or load, and the number of repetitions, and method of progression.209,210 Gentle exercises are prescribed in the first part of the healing phase. The main reasons for these early exercises are

• to encourage patient involvement;
• to provide mechanoreceptor stimulation;
• to control pain and inflammation;
• to promote healing;
• to maintain the newly attained ranges;
• to provide neuromuscular feedback.

AAROM/AROM211