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).
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.
Cervical extension, side bending and rotation.
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.
Neck retraction in extension.
Neck retraction in side bending.
Neck retraction in prone—start position.
Neck retraction in prone—terminal position.
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 rotation.
Resisted Cervical Side Bending
Resisted side bending tests the key muscle of C3, and cranial nerve XI (Fig. 25-19).
Resisted cervical side bending.
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).
Resisted shoulder elevation.
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:
fourth lateral intercostal space;
Chest expansion measurement.
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).
Resisted shoulder abduction.
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).
Resisted shoulder external rotation.
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).
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).
Resisted wrist extension.
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).
Resisted shoulder internal rotation.
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).
Resisted elbow extension.
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).
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).
Resisted thumb extension.
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).
Strength test for finger adductors (hand intrinsics).
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
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.
Muscle function testing of deep neck flexors.
Table 25-11 Common Faults in Performance of the Craniocervical Flexion Test and Suggestions for Correction ||Download (.pdf)
Table 25-11 Common Faults in Performance of the Craniocervical Flexion Test and Suggestions for Correction
The patient performs a neck retraction movement rather than the rotation action of craniocervical flexion
Teach the patient to initiate the movement with their eyes. Look down with the eyes and follow with a slow and controlled chin nod. Look up to the ceiling with the eyes only and follow with the chin to resume the neutral position. Emphasize the sliding of the occiput on the bed to achieve the pure craniocervical flexion. The clinician may guide the movement with fingers placed on either side of the patient's head.
The pressure change is achieved using excessive superficial muscle activity
Palpate the sternocleidomastoid and scalene muscles during the test, to give the patient an awareness of the superficial muscle contraction. Limit the range of craniocervical flexion to the point just short of palpating the dominant superficial muscle activity. Teach the patient self-palpation and an awareness of the correct action. EMG biofeedback may also be beneficial, while the patient practices a slow and controlled craniocervical flexion.
The patient rests in a position of flexion, with associated tension in the scalene muscles
Re-educate the awareness of the neutral position by focusing the eyes on the ceiling above the head, lifting the chin, and palpating the relaxation in the scalenes. Relaxation training may be required in cases of anxiety. Diaphragmatic breathing training can help to relax the respiratory accessory muscles.
There is evident jaw clenching and use of the jaw muscles
Instruct the patient in the relaxed position of the mandible—the anterior one-third of the tongue on the roof of the mouth, lips together, teeth apart.
The patient is holding their breath
Instruct in relaxed nasal breathing while performing the exercise
The patient performs the action quickly and often overshoots the target pressure
Reteach the craniocervical flexion action and emphasize that the movement should be slow and controlled.
Patient demonstrating weak neck flexors in the presence of a strong SCM.
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.
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.
Testing the holding capacity of the lower scapular stabilizers (clinician not shown).
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.
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.
Cervical flexion, contralateral side flexion and ipsilateral rotation. The amount of available rotation is minimal.
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.
Muscle length test of levator scapulae.
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.
More specific test to assess the muscle length of the levator scapulae.
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.
Muscle length test of the right sternocleidomastoid.
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.
Muscle length test of scalenes.
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!
The following muscle stretch reflexes should be checked for differences between the two sides:
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
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.
Sandmark and Nisell168 reported that palpation over the facet joints was the most appropriate screening to corroborate self-reported neck dysfunction.
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.
Palpation is a key component of the evaluation for cervical myofascial pain.170
The following muscles should be palpated for tenderness:
- 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
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.
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
Palpating the articular pillar just lateral to the spinous process.
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
Mobility Testing of Zygapophyseal Joints
Interpretation of Cervical Translatory Glides
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
Table 25-12 Usefulness of Passive Physiological Testing in the Cervical Spine ||Download (.pdf)
Table 25-12 Usefulness of Passive Physiological Testing in the Cervical Spine
PPM Test Level
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.
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).
Translational glides of cervical spine in flexion.
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.
Translational glides of cervical spine in extension.
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.
Segmental mobility testing of the cervicothoracic junction.
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.
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.
General distraction of cervical spine in supine.
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).
Left side bending/rotation with right translation at the C3–4 level.
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).
Rotation of superior segment in supine.
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.
Flexion and rotation to the right in supine.
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.
P-A pressures of cervical spine.
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.
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.
Cervical distraction in sitting.
Cervical compression in sitting.
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).
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
Table 25-13 The Northwick Park Neck Pain Questionnaire ||Download (.pdf)
Table 25-13 The Northwick Park Neck Pain Questionnaire
Neck pain intensity
I have no pain at the moment.
The pain is mild at the moment.
The pain is moderate at the moment.
The pain is severe at the moment.
The pain is the worst imaginable at the moment.
Neck pain and sleeping
My sleep is never disturbed by pain.
My sleep is occasionally disturbed by pain.
My sleep is regularly disturbed by pain.
Because of pain I have less than 5 hours sleep in total.
Because of pain I have less than 2 hours of sleep in total.
Pins and needles or numbness in the arms at night
I have no pins and needles or numbness at night.
I have occasional pins and needles or numbness at night.
My sleep is regularly disturbed by pins and needles or numbness.
Because of pins and needles I have less than 5 hours sleep in total.
Because of pins and needles or numbness I have less than 2 hours of sleep in total.
Duration of symptoms
My neck and arms feel normal all day.
I have symptoms in my neck or arms on waking which last less than 1 hour.
Symptoms are present on and off for a total period of 1–4 hours.
Symptoms are present on and off for a total of more than 4 hours.
Symptoms are present continuously all day.
I can carry heavy objects without extra pain.
I can carry heavy objects but they give me extra pain.
Pain prevents me from carrying heavy objects but I can manage medium weight objects.
I can lift only light-weight objects.
I cannot lift anything at all.
Reading and watching TV
I can do this as long as I wish with no problems.
I can do this as long as I wish if I'm in a suitable position.
I can do this as long as I wish but it causes extra pain.
Pain causes me to stop doing this sooner than I would like.
Pain prevents me from doing this at all.
I can do my usual work without extra pain.
I can do my usual work but it gives me extra pain.
Pain prevents me from doing my usual work for more than half the usual time.
Pain prevents me from doing my usual work for more than a quarter of the usual time.
Pain prevents me from working at all.
My social life is normal and causes me no extra pain.
My social life is normal but increases the degree of pain.
Pain has restricted my social life but I am still able to go out.
Pain has restricted my social life to the home.
I have no social life because of pain.
I can drive whenever necessary without discomfort.
I can drive whenever necessary but with discomfort
Neck pain or stiffness limits my driving occasionally.
Neck pain or stiffness limits my driving frequently.
I cannot drive at all due to neck symptoms.
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).
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.
Scalene cramp and relief tests.
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.
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).
Table 25-14 Evidence-Based Tests for Cervical Radiculopathy ||Download (.pdf)
Table 25-14 Evidence-Based Tests for Cervical Radiculopathy
Brachial plexus compression testd
Cervical hyperflexion (limited <55°)b
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
Brachial Plexus Compression Test without the sidebending.
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 hyperextension (Jackson's test).
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).
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.
Cervical Rotation Lateral Flexion Test.
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
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.
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.
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.
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
Hyperabduction Maneuver (Wright Test).
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.