The Cervical Spine Flashcards
Patients with neck pain make up what percentage of all patients seen in outpatient practice?
25%
During which decade of life is neck pain most prevalent?
50s
Which biological sex experiences neck pain more frequently?
women
What structure travels through the cervical transverse foraminae?
vertebral artery
Describe the vascular course of the vertebral artery
aortic arch -> subclavian -> vertebral -> basilar artery
How does the structure of C1 differ from other cervical vertebrae?
no vertebral body & no spinous process
What are the attachments of the alar ligaments?
dens -> occipital condyles of the cranium
What are the attachments of the transverse ligament?
horizontally at C1 (covers the dens)
What are the relevant ligaments of the upper cervical spine?
alar ligaments & cruciform ligament (transverse ligament & longitudinal bands)
What are the functions of the alar and cruciform ligaments?
they keep the dens in close approximation to the C1 articulation & away from the spinal canal during motion
What are the attachments of the longitudinal bands of the upper cervical cruciform ligament?
medially from transverse ligament -> superiorly to occiput -> inferiorly to C2
What are the relevant joints of the lower cervical spine?
facet (zygapophyseal) joints, articulation of vertebral bodies, uncovertebral joints
What is the ligamentum nuchae (nuchal ligament)?
broad expansive ligament that extends from the spinous process of C7 to the external occipital protuberance
What are 2 functions of the ligamentum nuchae?
increases the depth of the cervical spinous processes, allowing for muscular attachment & helps limit cervical flexion
List 4 relevant muscles of the posterior upper cervical spine.
- rectus capitis posterior major
- rectus capitis posterior minor
- obliquus capitis inferior
- obliquus capitis superior
Age < 50 years old, pain less than 12 weeks, symptoms isolated to the neck, and restricted cervical ROM are common to which Neck Pain Category?
Neck Pain with Mobility Deficits
What is the most common onset of symptoms for Neck Pain with Mobility Deficits?
recent unguarded/awkward movement or position & there can be associated (referred) upper extremity pain
List 3 competing serious diagnoses that should be ruled out before classifying a patient with Neck Pain with Mobility deficits?
- cervical fracture
- upper cervical instability / hypermobility
- vertebrobasilar/arterial insufficiency
What are 3 items to ask about during the subjective to screen for upper cervical instability or fracture?
- fall from height?
- MVA?
- Long-term exposure to corticosteroids? (RA, lupus, pulmonary conditions)
List 3 reasons that patients may have long-term exposure to corticosteroids
systemic problems:
- rheumatoid arthritis
- systemic lupus erythematosus
- pulmonary conditions
What are 3 clinical tests to assess for upper cervical ligamentous insufficiency?
- Sharp-Pursor test
- Alar ligament integrity test
- Central P-A segmental mobility
Which ligament is tested during the Sharp-Pursor test?
transverse portion of cruciform ligament of C1-2
List the 4 categories of neck pain as described by the International Classification of Functioning, Disability, and Health.
- Neck Pain with Mobility Deficits
- Neck Pain with Headaches
- Neck Pain with Movement Coordination Impairments
- Neck Pain with Radiating Pain
Which ICF Classification for neck pain is described below:
- age < 50
- acute pain
- restricted cervical ROM
- pain isolated to neck
Neck Pain with Mobility Deficits
Which ICF Classification for neck pain is described below:
- unilateral
- neck/suboccipital pain
- ipsilateral provocation of head/suboccipital symptoms during manual assessment
- restricted ROM
- restricted segmental mobility
- Cranial Nerve Flexion test (+)
Neck Pain with Headaches
Which ICF Classification for neck pain is described below:
- longstanding pain (over 3 months)
- Cranial Nerve Flexion test (+)
- Deep Neck Flexor test (+)
- weakness of neck and upper quarter muscles
- ergonomic inefficiencies with repetitive activities
Neck Pain with Movement Coordination Impairments
Which ICF Classification for neck pain is described below:
- Spurling’s (+)
- ULTT (+)
- Manual Traction (+)
- cervical rotation less than 60° toward involved side
- success with reducing upper extremity symptoms with initial interventions
Neck Pain with Radiating Pain
The following are the most effective treatments for which ICF neck pain category:
- cervical mobilization / manipulation
- thoracic mobilization/manipulation
- stretching exercise
- coordination, strengthening, & endurance exercise
Neck Pain with Mobility Deficits
The following are the most effective treatments for which ICF neck pain category:
- upper and/or lower cervical spine mobilization/manipulation
- stretching exercise
- coordination, strengthening, & endurance exercises
Neck Pain with Headache
The following are the most effective treatments for which ICF neck pain category:
- coordination, strengthening, & endurance exercise
- patient education & counseling
- stretching exercise
Neck Pain with Movement Coordination Impairments
The following are the most effective treatments for which ICF neck pain category:
- upper quarter & nerve mobilization procedures
- cervical traction
- thoracic mobilization/manipulation
Neck Pain with Radiating Pain
List 4 of the most effective treatments for neck pain with mobility deficits.
- cervical mobilization/manipulation
- thoracic mobilization/manipulation
- stretching exercises
- coordination, strengthening, & endurance exercise
List 3 of the most effective treatments for neck pain with headaches.
- upper and/or lower cervical mobilization/manipulation
- stretching exercises
- coordination, strengthening, & endurance exercises
List 3 of the most effective treatments for neck pain with movement coordination impairments.
- coordination, strengthening, & endurance exercises
- patient education & counseling
- stretching exercise
List 3 of the most effective treatments for neck pain with radiating pain.
- upper quarter and nerve mobilization procedures
- cervical traction
- thoracic mobilization/manipulation
The C5 nerve root involvement can result in weakness of which muscle(s)?
Deltoid (test at 90° abduction)
The C6 nerve root involvement can result in weakness of which muscle(s)?
Biceps brachii & Extensor Carpi Radialis Longus/Brevis (test with wrist in extension and radial deviation)
The C7 nerve root involvement can result in weakness of which muscle(s)?
Triceps (test with arm overhead, elbow in slight flexion) & Flexor Carpi Radialis (test in wrist flexion and radial deviation)
The C8 nerve root involvement can result in weakness of which muscle(s)?
Abductor Pollicis Brevis
The T1 nerve root involvement can result in weakness of which muscle(s)?
First Dorsal Interossei (test by resisting finger abduction)
Which dermatomal area is associated with the C5 nerve root?
Lateral forearm
Which dermatomal area is associated with the C6 nerve root?
Distal thumb
Which dermatomal area is associated with the C7 nerve root?
Distal middle finger
Which dermatomal area is associated with the C8 nerve root?
Distal fifth finger
Which dermatomal area is associated with the T1 nerve root?
Medial forearm
Which reflex tests the C5 nerve root?
biceps brachii
Which reflex tests the C6 nerve root?
brachioradialis
Which reflex tests the C7 nerve root?
triceps
The biceps reflex tests which nerve root?
C5
The brachioradialis reflex tests which nerve root?
C6
The triceps reflex tests which nerve root?
C7
Which dermatomal area is supplied by the same nerve root associated with the biceps reflex?
lateral forearm (nerve root C5)
Which dermatomal area is supplied by the same nerve root associated with the brachioradialis reflex?
distal thumb (C6)
Which dermatomal area is supplied by the same nerve root associated with the triceps reflex?
distal middle finger (C7)
Which dermatomal area is supplied by the same nerve root associated with the abductor pollicis brevis?
distal fifth finger (C8)
Which dermatomal area is supplied by the same nerve root associated with the first dorsal interossei?
medial forearm (T1)
Name the reflex that is most closely associated with lateral forearm sensation
biceps brachii reflex (C5)
Name the reflex that shares a nerve root with distal thumb sensation
brachioradialis reflex (C6)
Name the reflex that “shares” a nerve root with distal middle finger sensation
triceps reflex (C7)
Injury or sensitivity of which nerve root is most closely associated with:
- deltoid weakness
- lateral forearm sensation change
- altered biceps reflex
C5 nerve root
Injury or sensitivity of which nerve root is most closely associated with:
- biceps / ECRL weakness
- distal thumb sensation change
- altered brachioradialis reflex
C6 nerve root
Injury or sensitivity of which nerve root is most closely associated with:
- triceps / FCR weakness
- distal middle finger sensation change
- altered triceps reflex
C7 nerve root
Injury or sensitivity of which nerve root is most closely associated with:
- thumb abduction (APB) weakness
- distal fifth finger sensation change
- reflexes intact
C8 nerve root
Injury or sensitivity of which nerve root is most closely associated with:
- finger abduction (1st DI) weakness
- medial forearm sensation change
- reflexes intact
T1 nerve root
Compare and contrast the nerve supply and reflex testing of the biceps brachii vs brachioradialis muscles.
Both are supplied by the C5 & C6 nerve roots. C5 is tested with the biceps reflex, while C6 is tested with biceps strength & the brachioradialis reflex
List 4 of the most common exam findings for Neck Pain with Mobility Deficits
- younger person (< 50)
- acute neck pain
- symptoms isolated to neck
- restricted cervical ROM
List 6 of the most common eval/exam findings for Neck Pain with Headaches.
- U/L headache associated with neck/suboccipital sx
- headaches are aggravated with neck movements / positions
- headaches produced/aggravated with provocation of ipsilateral cervical structures (myofascia/joints)
- restricted cervical ROM
- restricted cervical segmental mobility
- (+) Cranial Cervical Flexion test
List 6 of the most common eval/exam findings for Neck Pain with Movement Coordination Impairments.
- longstanding neck pain (3 months +)
- (+) Cranial Cervical Flexion test
- (+) Deep Neck Flexor test
- coordination, strength, & endurance deficits of neck and upper quarter muscles
- Flexibility deficits of upper quarter muscles
- ergonomic inefficiencies with performing repetitive activities
List 7 of the most common exam findings for Neck Pain with Radiating Pain.
- upper extremity symptoms (referred/radicular)
- (+) Spurling’s
- (+) ULTT
- (+) Traction
- decreased ipsilateral cervical rotation (< 60°)
- signs of nerve root compression (myotome/dermatome)
- initial intervention reduces upper extremity sx
Describe the performance of the Sharp-Purser test. What constitutes a positive/negative test?
- patient seated
- PT stabilizes spinous process of C2 and places the other hand on the forehead
- passively flex 20°-30°
- push forehead posteriorly
- (-) if PT feels C2 immediately move posteriorly
- (+) if cranial movement occurs (subluxation is reduced)
- (+) of myelopathic symptoms are reproduced with flexion portion
- (+) if sx are decreased with posterior translation
What are the general sensitivity and specificity of the Sharp-Purser test?
excellent specificity (96%), moderate sensitivity (69%)
Describe the Alar Ligament test.
- pt is supine
- PT stabilizes C2 spinous process with a pinch grip
- passively side-bend head
- (-) if C2 spinous process moves immediately into finger pad on opposite side of the bend
- (+) if movement is delayed
What are the 5 criteria (identified by Hoffman et al) to identify patients with acute neck pain that are unlikely to need imaging studies? What are the general sensitivity and specificity of the decision instrument
- no midline cervical tenderness
- no focal neurologic deficit
- normal alertness
- no intoxication
- no painful, distracting injury
- excellent sensitivity (99.6%), low specificity (12.9%)
What are the 3 most important conditions that need to be considered before implementing techniques and exercises to improve cervical mobility?
- upper cervical instability / hypermobility (ligamentous injury)
- fracture
- vertebrobasilar vascular insufficiency
List 8 historical/clinical features suggestive of vertebral artery dissection.
- most common sx are unilateral suboccipital / head pain
- patient never experienced a similar pain before
- onset often acute (related to trauma or spontaneous)
- high severity
- “sharp” quality
- stiffness without ROM loss
- time delay between MOI and symptoms (up to 2 weeks)
- cranial nerve signs (5D’s and 3 N’s)
What are the 5 D’s and 3 N’s? List them
Signs and symptoms of Vertebrobasilar Insufficiency
- Diplopia (vision problems)
- Dizziness
- Drop Attacks (sudden weakness in arm/face/leg)
- Dysarthria (speech problems)
- Dysphagia (swallowing problems)
- Ataxia (often unilateral)
- Nausea/vomiting
- Numbness (often unilateral)
- Nystagmus
What is the most common cause of sudden-onset vertebrobasilar insufficiency?
trauma, specifically from high-velocity, flexion-distraction & rotational forces that may occur during whiplash
Describe the physical examination process used by the monograph author (Michael Miller) to screen for vertebrobasilar insufficiency.
- AROM extension, rotation, and side-bending (“look up and over your shoulder”). If ROM is full or limited by stiffness, proceed.
- Maintain patient’s head in the position in which the manual procedure will be performed for 10-15 seconds, assessing for VBI sx
When measuring active cervical flexion, extension, & lateral flexion with an inclinometer, how should the device be positioned?
- on top of the head, in line with the external auditory meatus
What is the normal amount of active cervical flexion?
patient should be able to bring chin to chest (even in cases of extreme degenerative changes)
When measuring active cervical rotation with a goniometer, how should the device be positioned?
- stationary arm: in line with the acromion
- moveable arm: in line with the nose
During the physical exam of a joint, AROM is painless, what should be performed next in the physical exam? What should be assessed?
- overpressure at all end-ranges
- assess ROM, symptom response, and end-feel
Manual P-A assessment of a patient with neck pain should include which segments?
C2-T4 (upper thoracic spine can contribute to neck pain)
When assessing cervical segmental mobility in supine, passive extension + right-to-left motion simulates what cervical movements?
extension, right side-bending, & right rotation at that segment (“closing” on the right)
In segmental cervical assessment, what is meant by a right “closing” problem?
limited extension, ipsilateral side-bending, and ipsilateral rotation
In segmental cervical assessment, what is meant by a right “opening” problem?
limited flexion, contralateral side-bending, contralateral rotation
When assessing cervical segmental mobility in supine, passive flexion + right-to-left motion simulates what cervical movements?
flexion, right side-bending, right rotation (“opening” on the left)
When assessing cervical segmental mobility in supine, passive extension + left-to-right motion simulates what cervical movements?
extension, left side-bending, left rotation (“closing” on the left)
When assessing cervical segmental mobility in supine, passive flexion + right-to-left motion simulates what cervical movements?
flexion, right side-bending, right rotation (“opening” on the left)
Describe the procedure for measuring anterior & middle scalene muscle length
- stabilize medial clavicle & 1st rib
- cradle the occiput & stabilize the forehead with your shoulder
- extend the lower cervical spine while maintaining neutral upper cervical spine
- contralateral side-bending & ipsilateral rotation
How are levator scapulae & posterior scalene muscle length tested?
- depress the scapula
- cradle the occiput & stabilize the forehead with your shoulder
- flex the cervical spine
- contralateral side-bending & contralateral rotation
How is upper trapezius muscle length tested?
- stabilize the scapula
- cradle the occiput & stabilize forehead with your shoulder
- flex the cervical spine
- contralateral side-bending & ipsilateral rotation
When assessing upper trapezius length, what can result in a false impression that the muscle is shortened?
If the patient presents with a depressed or downwardly (medially) rotated scapula, the upper trap is already lengthened & symptom reproduction with upper trap length testing may be a false positive. (in which case, you wouldn’t want to stretch the upper trap more)
List 4 differences between HVLA thrust manipulation vs non-thrust mobilization of the upper cervical and upper thoracic spine in patients with neck pain, according to the study performed by Dunning et al.
At 48 hours, HVLA thrust group experienced:
- greater reduction in pain
- greater reduction in disability
- greater improvement in passive C1-2 rotation
- greater increases in motor performance of the deep cervical flexor muscles
What is the most accepted theory of the mechanism behind spinal manipulation?
spine manipulations act over central pain control by stimulating descending inhibitory pain mechanisms (particularly the periaqueductal gray)
List the 4 attributes of neck pain patients who will likely respond favorably to thrust joint manipulation of the cervical spine, according to Puentadora et al? How many of these attributes need to be present to increase the likelihood of success?
- Relatively acute (symptom duration less than 38 days)
- positive expectation that manipulation will help
- side-to-side difference in cervical rotation of 10° or greater
- pain with P-A of middle cervical spine
3 or 4 of these present = 90% probability of success (2 = 68%)
Describe the rotation manipulation for a patient that has right-sided neck pain with flexion, and/or left rotation, and/or left side-bending
- pt supine, arms at sides
- upper cervical spine is flexed (chin tuck)
- PT’s right MCP joint of index finger is on right facet joint (creates a fulcrum point), left MCP joint of index finger is placed on the articular pillar of upper level of segment being treated (C5 if treating C5-6)
- flex the cervical spine until motion is palpated at the involved segment
- establish fulcrum & take up the barrier into left rotation & left side-bending
- apply HVLA thrust into left rotation with right hand
(“opening” technique)
Describe the rotation manipulation for a patient that has left-sided neck pain with flexion, and/or right rotation, and/or right side-bending
- pt supine, arms at sides
- upper cervical spine is flexed (chin tuck)
- PT’s left MCP joint of index finger is on left facet joint (creates a fulcrum point), right MCP joint of index finger is placed on the articular pillar of upper level of segment being treated (C5 if treating C5-6)
- flex the cervical spine until motion is palpated at the involved segment
- establish fulcrum & take up the barrier into right rotation & right side-bending
- apply HVLA thrust into right rotation with right hand
(“opening” technique)
Describe the translational manipulation for a patient that has left-sided neck pain with flexion, and/or right side-bending, and/or right rotation.
- pt is supine, arms at sides
- create upper cervical flexion (chin tuck)
- using index and middle fingers of both hands, flex the cervical spine until motion is palpated at the involved segment
- using right 2nd MCP joint, apply a right-to-left (restricted side) translation to create right side-bending and right rotation in flexion
- apply HVLA thrust into left translation with right 2nd MCP
(“opening” technique)
Describe the translational manipulation for a patient that has right-sided neck pain with flexion, and/or left side-bending, and/or left rotation.
- pt is supine, arms at sides
- create upper cervical flexion (chin tuck)
- using index and middle fingers of both hands, flex the cervical spine until motion is palpated at the involved segment
- using left 2nd MCP joint, apply a left-to-right (restricted side) translation to create left side-bending and left rotation in flexion
- apply HVLA thrust into right translation with left 2nd MCP
(“opening” technique)
Describe the non-thrust mobilization for a patient that has left-sided neck pain with flexion, and/or right side-bending, and/or right rotation
- pt is supine, arms at sides
- create upper cervical flexion (chin tuck)
- using middle and index fingers of right hand, palpate the right articular pillar & flex the involved segment
- support the head with the left forearm & left hand cupping the chin
- flex the spine & stand slightly to the patient’s right
- maintain cervical flexion & chin tuck as you create right rotation in flexion with left forearm
- right hand applies superior/anterior-directed force at the articular pillar
- “opening” technique or “upglide” of left facet joint
Describe the non-thrust mobilization for a patient that has right-sided neck pain with flexion, and/or left side-bending, and/or left rotation
- pt is supine, arms at sides
- create upper cervical flexion (chin tuck)
- using middle and index fingers of left hand, palpate the left articular pillar & flex the involved segment
- support the head with the right forearm & right hand cupping the chin
- flex the spine & stand slightly to the patient’s left
- maintain cervical flexion & chin tuck as you create left rotation in flexion with right forearm
- left hand applies superior/anterior-directed force at the articular pillar
- “opening” technique or “upglide” of left facet joint
Describe a manipulation for a patient that has right-sided neck pain with extension, and/or right side-bending, and/or right rotation
- pt is supine, arms at sides, head at the edge of the table
- using middle and index fingers of right hand, palpate the right and left articular pillars of the involved vertebra
- left hand lays flat of the left side of the patient’s head (near temple)
- create extension with vertebra at the apex
- apply a right-to-left translation with right 2nd MCP joint (to create right side-bending and right rotation)
- HVLA thrust with right 2nd MCP in a left/inferior direction
- “closing” technique
Describe a manipulation for a patient that has left-sided neck pain with extension, and/or left side-bending, and/or left rotation
pt is supine, arms at sides, head at the edge of the table
- using middle and index fingers of left hand, palpate the right and left articular pillars of the involved vertebra
- right hand lays flat of the right side of the patient’s head (near temple)
- create extension with vertebra at the apex
- apply a left-to-right translation with left 2nd MCP joint (to create left side-bending and left rotation)
- HVLA thrust with left 2nd MCP in a right/inferior direction
- “closing” technique
Describe an exercise that you might give to a patient that had relief with a cervical manipulation to improve flexion and/or right rotation/side-bending
- pt is sitting
- with right hand, pt hooks the spinous process or the left articular pillar using index or middle finger
- pt looks down and to the right, pulling anteriorly with right hand assisting the segment into flexion and right rotation
Describe an exercise that you might give to a patient that had relief with a cervical manipulation to improve flexion and/or left rotation/side-bending
- pt is sitting
- with left hand, pt hooks the spinous process or the right articular pillar using index or middle finger
- pt looks down and to the left, pulling anteriorly with left hand assisting the segment into flexion and left rotation
Describe an exercise that you might give to a patient that had relief with a cervical manipulation to improve extension and/or right rotation/side-bending
- pt is sitting with a towel wrapped around the back of the neck
- edge of towel is placed at involved segment
- pt grabs each end of the towel & pulls left and down
- pt then looks up & right
Describe an exercise that you might give to a patient that had relief with a cervical manipulation to improve extension and/or left rotation/side-bending
- pt is sitting with a towel wrapped around the back of the neck
- edge of towel is placed at involved segment
- pt grabs each end of the towel & pulls right and down
- pt then looks up & left
One of the most common challenges in headache evaluation is distinguishing cervicogenic headache from a migraine. What is the estimate for how often a patient is misdiagnosed?
studies show that incorrect headache diagnosis may occur in more than 50% of cases
When assessing suspected neck pain with headaches, careful attention should be paid to which movement? Why?
- rotation
- up to half of normal rotation ROM (39°-45°) occurs at C1-2, and this articulation has a high frequency of symptomatic involvement in patients with neck pain with headaches
If cervical rotation is less than 45°, you may suspect a problem is likely at which articulation?
C1-2 (39°-45° of normal rotation occurs here)
When assessing neck pain, what are 2 ways to help to differentiate a C1-2 limitation vs a lower cervical spine limitation
- rotation ROM less than 45° = likely C1-2 involvement
2. rotation ROM greater than 45°, perform the Cervical Flexion Rotation Test
Describe the Cervical Flexion Rotation test.
- pt is supine
- maximally flex head & neck
- maintain flexion and passively rotate head & neck in each direction
- normal ROM is ~45°
- (+) if there is a 10° reduction in visually estimated ROM on either side
How sensitive/specific is the Cervical Flexion Rotation Test?
high sensitivity and specificity for identifying cervicogenic headache (Sn 91%, Sp 90%-100%)
How many degrees does the Cervical Flexion Rotation test need to change in order to be confident that the patient actually gained ROM?
at least 7°
What are 2 way to assess motion of the skull on C1?
- have patient to nod their head while maintaining a neutral spine
- have patient rotate and then perform capital nod (compare sides)
When patients with migraine and those with cervicogenic headache are compared, how do they differ clinically?
Patients with cervicogenic headache have less ROM into cervical flexion & extension in addition to significantly higher incidence of painful upper cervical joint dysfunction (manual exam and muscle tightness)
Describe muscle length / provocation testing for suboccipital musculature.
- pt is supine, arms at sides
- stabilize C2 using 2nd finger with other hand overlapping it
- shoulder stabilized patient forehead
- create upper cervical flexion while stabilizing C2
- rotate 20°-30° to the right to assess length of right suboccipitals, left to assess the left side
- compare side to side for ROM and sx reproduction
If a patient has difficulty attaining a neutral cervical spine during the Cranial Cervical Flexion test, what modification should be made?
add towels behind their head/neck
Describe the Cranial Cervical Flexion test.
- pt is supine, arms at sides
- pneumatic pressure feedback device (or blood pressure cuff) is inflated to 20 mmHg to fill the space between the cervical lordosis & the table
- pt is instructed to keep posterior head / occiput stationary (“do not lift, do not push down”)
- pt performs cranial flexion in a graded manner in 5 incremements (22, 24, 26, 28, and 30 mmHg)
- “nod your head as if you are saying ‘yes’ with the upper neck”
- goal is to hold each position for 10 seconds with 10 seconds rest between each
- during the test, palpate to ensure that superficial musculature isn’t being recruited (e.g. sternocleidomastoid)
- test is ended if pressure drops by more than 20% or pt is unable to perform movement properly
What is the normal response to the Cranial Cervical Flexion test?
26-30 mmHg seconds for 10 seconds without using superficial muscle substitution
List 4 abnormal responses to the Cranial Cervical Flexion test that would indicate a (+) test
- unable to generate at least 6 mmHg of pressure
- unable to hold pressure for 10 seconds
- uses superficial neck muscles
- uses a sudden movement of the chin or pushing (extending) the neck forcefully against pressure device
When administering the Cranial Cervical Flexion test, the patient may substitute with superficial musculature such as the platysma or hyoid. How should you cue the patient to try to minimize this muscle involvement?
“place your tongue on the roof of your mouth, keep your lips together, and keep your teeth slightly separated”
The Cranial Cervical Flexion test is recorded with both an activation score & a performance index. How are these outcomes determined?
- activation score: pressure achieved and held for 10 seconds (in mmHg)
- performance index: increase in pressure x number of repetitions
What is the statistical measurement ICC? What is considered a poor, moderate, good, or excellent ICC?
- Interclass Correlation Coefficient
- used to measure reliability of ratings in studies where there are two or more raters
- scale is between 0-1
- 0-0.5 = poor reliability
- 0.5-0.75 = moderate reliability
- 0.75-0.9 = good reliability
- 0.9-1 = excellent reliability
Research has shown significant differences in the Cranial Cervical Flexion test in which two populations?
people with tension-type headaches & older people (60-75 years old)
Describe the Neck Flexor Muscle Endurance test.
- pt is supine in hooklying, arms at sides
- pt is instructed to maximally retract chin & lift head/neck 1 inch from the table
- place hand flat under patient’s head (occiput)
- watch for the skin folds on the anterior neck due to the chin tuck
- if skin fold is lost or of the head touches your hand for more than 1 sec, the test is ended and considered (+)
What are the mean hold time for the Deep Neck Flexor Muscle Endurance test for healthy, pain-free subjects?
~40 seconds for men & ~30 seconds for women
Describe the Upper Cervical Contract-Relax procedure to improve C1-2 rotation.
- pt is supine
- create full passive captial/cervical flexion & passive rotation to end of available ROM
- pt is instructed to perform gentle isometric rotation into opposite direction (“look or turn gently”) & hold for 3-5 seconds
- at the end of the contraction, take the head and neck further into the restricted range
- repeat isometric contraction 3-5 times
- consider additional contraction actively into the direction of the restricted range (maintain/train muscles into the new range)
Describe a seated C1-2 mobilization for a patient with limited/painful cervical rotation.
- pt sitting in chair
- hug the head with anterior arm
- use thumb of other hand to stabilize transverse process of C2 on the side of the limitation
- apply anterior force onto transverse process of C2, slightly tilt the head away, & use anterior arm to create head and C1 rotation toward the limited side on a stable C2
Describe the Upper Cervical Contract-Relax Procedure to improve Occiput-C1 flexion. When would you apply this technique?
- for patients that have limited/painful upper cervical flexion
- pt is supine
- create capital flexion & laterally translate the head to the most limited side
- place the index finger of the hand on the side of the translation on the patient’s chin
- instruct the patient to look up over to the side they are shifted to
- resist this motion and hold for 5 seconds
- at the end of the contraction, take the head into slightly more capital flexion & lateral translation, then repeat the contraction
- repeat this process 3-5 times
Describe 2 mobilizations to improve general Occiput-C1 mobility. When might you apply this technique?
- for patients that have limited/painful upper cervical segmental testing and/or active flexion
1. ) UPA glide on articular pillar of C1 in prone
2. Supine mobilization: - use middle phalanx to stabilize articular pillar of C1, stabilizing with palm of other hand
- apply P-A force to forehead through the shoulder (same side as targeted segment)
Describe a manipulation technique for a patient with limited/painful upper cervical flexion.
- pt is supine with legs straight
- stand toward the side of the patient opposite the targeted side
- use 2nd MCP of non-target-side hand to contact the occipital condyle
- hug the patient’s head to your chest by wrapping your other hand/forearm around the head (palm flat by the side of the chin)
- take the patient to end-range capital flexion & translate the head toward the targeted side
- provide a distracting force by shifting weight
- HVLA thrust through 2nd MCP with quick weight shift into distraction
Which muscles are referred to as the “deep neck flexors”?
longus capitis & longus colli
What is the general state of the evidence regarding physical therapy intervention and headaches?
manual therapy, strengthening/endurance exercise, stretching, and postural education are effective in reducing (1) frequency and (2) disability in patients with cervicogenic headaches; the benefits are typically maintained at one-year follow-up
List the 4 ICF impairments of body function associated with neck pain with movement coordination impairments:
- strength, endurance, & coordination deficits of deep neck flexors
- pain with mid-range motion that worsens in end-range movements/positions
- pain in neck/upper extremity with segment provocation
- instability may be present (muscle guarding/spasm) that interferes with testing
During the examination of a patient with neck pain with movement coordination impairments, what might make you suspect cervical instability? What is the next course of action to take?
- muscle guarding / spams that interferes with accurate testing
- if you suspect instability, perform the ligamentous integrity tests
- assess for symptoms of VBI involvement
What substitution pattern do patients with limited/painful cervical rotation often display during the AROM assessment?
extension and/or side-bending
What examination activity is typically not included in the assessment of neck pain with movement coordination impairments?
muscle length (may be indicated later, as patient’s symptoms resolve)
Discuss the relationship between people with whiplash and cervical muscle weakness.
- sharp reduction of 90% isometric strength vs healthy controls
- in the absence of severe atrophy or gross neurologic dysfunction, weakness may be associated with learned pain behavior
Dermatome and myotome testing for a patient with neck pain with radiating pain should assess which nerve roots?
C5, C6, C7, C8, & T1
List 3 clinical neurological signs that are associated with peripheral neuropathy (ex. cervical radiculopathy)
- numbness
- tingling
and/or - specific muscle weakness
List 7 clinical neurological signs that are associated with upper motor neuron pathology
- HYPERreflexia of upper and/or lower extremities
- more diffuse sensory changes (not follow dermatomal pattern)
- clonus of ankle
- (+) Hoffman’s sign
- (+) Babinski
- clumsiness of gait
- generalized weakness below level of compression
List 3 clinical neurological signs that are associated with lower motor neuron pathology
- HYPOreflexia (absent tendon reflex)
- decreased sensation to light touch following dermatomal pattern
- muscle weakness following myotomal pattern
Do lower or upper motor neuron lesions cause hyperreflexia of deep tendon reflexes?
upper motor neuron lesions
Do lower or upper motor neuron lesions cause hyporeflexia of deep tendon reflexes?
lower motor neuron lesions
Contrast sensory changes that take place with upper vs lower neuron lesions
- upper: diffuse sensory changes not in dermatomal pattern
- lower: decreased light touch in specific dermatomal pattern
Describe the common measuring scale for deep tendon reflex testing?
4+ hyperactive (upper motor neuron lesion) 3+ hyperactive but WFL 2+ normal 1+ hypoactive reflex 0 absent
What is the general specificity/sensitivity of deep tendon reflex testing for the upper quarter?
for C5, C6, and C7, the sensitivity is really low, but the specificity is generally in the mid- to high-90s (excellent)
What is the best single neurologic screening test for the diagnosis of cervical radiculopathy? Why?
C5 nerve root DTR testing (biceps reflex)
if the biceps reflex is diminished or absent, the chance of having a cervical radiculopathy increases from 23% to 59%
Describe the Babinski reflex test
- pt is supine with foot in neutral position
- blunt end of reflex hammer is moved on plantar surface from medial to lateral and from the heel to the metatarsal heads
- (-) if toes flex with smaller digits greater than the great toe
Describe the Hoffman reflex test
- pt is sitting or standing
- stabilize middle finger and flick distal phalanx
- (+) if flexion IP joints of thumb occurs with/without flexion of index fingers IP joints
What does a (+) Hoffman reflex indicate? How sensitive is the Hoffman reflex?
may indicate intracranial pathology or spinal cord compression; excellent sensitivity (94%)
What care should be taken when assessing segmental motion in a patient with neck pain with radiating pain?
muscle guarding may hamper manual segment motion assessment
Length of which muscles warrant close consideration when examining a patient with neck pain with radiating pain? Why?
scalenes and/or pec minor because of their association with nerves around the cervical spine and shoulder girdle (can mimic some of the signs & sx of neck pain with radiating pain)
The Upper Limb Tension Test is (+) if any of which 3 criteria are met?
- reproduction of all or part of the patient’s symptoms
- side-to-side differences of greater than 10° for ROM at the same sensitizing joint
- determine the location on the symptomatic side (decreased symptoms when a joint at least two segments away is moved)
What is the general specificity/sensitivity of the Upper Limb Tension Test?
sensitivity is excellent (~97%), specificity is poor (~22%)
The Upper Limb Tension test has generally poor specificity in detecting cervical radiculopathy (~22%). How can the specificity of the test be increased?
look for concordant symptoms: sensitization & asymmetry from side-to-side
Describe the performance of the Spurling test.
- pt is seated
- neck is guided into ipsilateral side-bending and slight rotation
- place a compression force of up to 15lb through the top of the head
- (+) if symptoms are reproduced
When should the Spurling test not be performed?
if patient has no upper extremity or scapular region symptoms
What is the general specificity/sensitivity of the Spurling test?
specificity is good (~90%), sensitivity isn’t great (~50%)
Describe the performance of the cervical Distraction test
- pt is supine
- grasp under chin & occiput
- flex neck to comfortable position
- apply distraction force of up to 30 lbs
- (+) if upper extremity or scapular sx are reduced
When should the cervical Distraction test not be performed?
if the patient has no symptoms in the upper extremity or scapular regions
What is the general specificity/sensitivity for the cervical Distraction test?
specificity is very good (~90%), but sensitivity is not great (~44%)
List the 4-item cluster to consider for a pattern of neck pain with radiating pain. How many items need to be present for the cluster to be considered highly specific for cervical radiculopathy?
- cervical rotation AROM less than 60° to involved side
- ULTT A (median nerve)
- Distraction test
- Spurling test
high specificity for cervical radiculopathy if 3 or 4 are present (99% if all 4)
Describe the purpose & performance of the Valsalva maneuver in assessing a patient with neck pain with radiating pain.
- to elicit upper quarter symptoms via increase in intrathecal pressure (fluid between layers that cover the spinal cord)
- pt is seated & instructed to take a deep breath, hold it, and exhale for 2-3 seconds
- (+) if symptoms are reproduced
What is the general specificity and sensitivity of the Valsalva maneuver for neck pain with radiating pain?
specificity is excellent (~94%), but sensitivity is bad (~22%)
Describe performance and interpretation of the Shoulder Abduction sign.
- pt sitting or lying down
- involved arm is actively or passively raised above the head & the palm is flat on the head
- (+) if arm symptoms are reduced (decreased traction on the nerve)
- (-) if symptoms increase (due to interscalene muscle compression)
List the 5 items in the cervical traction CPR
- peripheralization of symptoms with lower cervical spine (C4-7) mobility testing
- (+) Shoulder Abduction sign
- 55 years or older
- (+) ULTT
- relief of symptoms with manual traction
What is the general specificity/sensitivity of the cervical traction CPR?
if 3 or more of the 5 criteria are met, the specificity is excellent (~97%-100%), but the sensitivity is low (~30%)
- if 2 of 5 are met, the specificity is moderately high (~87%)
