Cervical Spine Examination

and Intervention
Daemen College DPT Program

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 Objectives
• Review the anatomy, biomechanics, and
arthrokinematics of the cervical spine.
• Introduce a sequence of examination tests and
measures designed to arrive at a patient
classification for cervical spine disorders.
• Analyze patient responses to repeated end range
cervical motions to determine appropriateness of
exercises based on direction of preference.
• Evaluate the cervical spine to determine the
presence of hypermobility and instability.
• Apply appropriate exercise and manual physical
therapy interventions designed to improve cervical
spine mobility, stability, and function

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 Cervical Spine Examination
• History/Subjective • Neurological –
• Structural dermatomes,
• AROM myotomes, muscle
stretch reflexes,
• Repeated movements neurodynamic testing
• PROM (PIVM) • Palpation
• Muscle performance • Special tests
– deep neck flexor
strength and
endurance, muscle
balance tests
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 Subjective Examination
• Area
• Nature
• Behavior
• Mechanism of injury
• Duration
• Review of systems
• Functional limitations/perceived level of
function

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 Neck Disability Index
• Vernon H, Mior S.
• A modification of the Oswestry Low Back Pain
Index
• Test-retest reliability was conducted on an initial
sample of 17 consecutive whiplash patients
(r=0.89, p,>05)
• Concurrent validity was established through
comparing NDI scores with McGill Pain
Questionnaire (correlations 0.69-0.70)

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 Differential Diagnosis
• What is the first order classification?
• Is the patient’s condition warrant referral to
another medical professional?
• What further tests/measures are
indicated?

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 Medical Diagnosis Examples
• ICD – 9 – CM
– 724 – unspecified disorder of the back
– 839.0 – dislocation, cervical (closed)
– 847 – sprains and strains of parts of the back

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Associated with Spinal Disorders – Pattern 4F

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Connective Tissue Dysfunction – Pattern 4D

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 Structural Examination
• Detailed examination of alignment and
structure from anterior, posterior, lateral
views
• Head tilt, torticollis
• Examination of sitting posture
• Correlation of symmetry to back pain –
Levangie PK. The association between
static pelvic asymmetry and low back pain.
Spine. 2000;2551-2552.
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 AROM
• Quality and quantity of movement through
goniometric measures and observation of
quality of movement
• Flexion
• Extension
• Sidebending
• Rotation

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 Cervical Spine Repeated
Movements
• Protraction • Retraction
• Retraction • Retraction with extension
• Retraction with extension • Above testing in supine
• Above testing in • Baseline prior to each
weightbearing test movement
• Baseline prior to each • PDM or ERP
test movement • Deviations
• PDM or ERP • Repeated sidebending
• Deviations and repeated rotation
tested in sitting if no
effect from saggital plane
movements
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 Assessment of patient responses
to repeated movements
• Increased • Centralized
• Decreased • Peripheralized
• Increased/no worse • Worse
• Decreased/no better • Better
• No effect

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 Neck Retractions, Cervical Root
Decompression, and Radicular
Pain
• Abdulwahab SS, Sabbahi M. JOSPT.
2000;30:4-12.
• Neck retractions appeared to alter H reflex
amplitude. These exercises may promote
cervical root decompression and reduce
radicular pain in patients with C7
radiculopathy
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 Reliability of McKenzie
Classification of Patients with
Cervical or Lumbar Pain
• Clare HA, Adams R, Maher CG, J.
Manipulative Physiol Ther. 2005; 28:122-127.
• The reliability for syndrome classification was
k=0.84 with 96% agreement for the total patient
pool, and k=0.63 with 92% agreement for
cervical patients.
• The reliability for subsyndrome classification was
k=0.87 with 90% agreement for the total patient
pool, and k=0.84 with 88% agreement for the
cervical patients
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 PROM
• Assessment of end feel (may avoid end range
rotation in certain patients)
• Flexion
• Extension
• Sidebending
• Rotation
• What are the normal end feels for the cervical
spine?
• What tissues are placed on stretch with
assessment of the end feel?
• Are other passive tests indicated?
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 Passive intervertebral motion
testing (PIVM)
• Also referred to as single segmental mobility
testing (SSMT)
• Flexion, extension, sidebending, rotation in
weightbearing and nonweightbearing positions
• Palpation between or lateral to spinous
processes
• Poor to moderate kappa coefficients – cervical
(Fjellner et al., 1999, Smedmark, Wallin,
Arvidsson, 2000).

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Lateral mobility, A-P, and P-A Tests
• Lateral mobility also referred to as position
testing
• Lateral translation (sidegliding) in neutral,
flexion, extension
• A-P segmental mobility
• P-A segmental springing from prone

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 Muscle Performance
• Isometric resistive testing
• Specific Manual muscle tests
• Muscle performance – strength and
endurance of the deep neck flexors

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 Neurological testing
• Dermatomes
• Myotomes
• Muscle stretch reflexes
• Tests for Adverse neural tension

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 Adverse neural tension testing
• Upper limb tension tests (ULTT) – median,
radial, ulnar
• Brachial plexus tension test
• Elvey test

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 Neurodynamic testing
• Based on adverse neural tension test
(Brachial plexus stretch, Elvey’s)
• Assess upper cervical flexion mobility for
range and reproduction of symptoms
• Return to cervical neutral and place
patient in Elvey’s position
• Reposition patient in upper cervical flexion
and observe response.
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 Special tests
• Compression
• Foraminal compression
• Distraction
• Vertebral artery
• Quadrant test
• Tests for space occupying lesion
Valsalva, DeJorines Triad (coughing,
sneezing, straining)

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 Palpation
• Tissue texture abnormalities
Skin rolling
Skin puckering
Tone
Ligamentous tenderness

• Positional faults, symmetry

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 Palpation
• Articular pillars
• Spinous processes
• Transverse processes
• External occipital protuberance
• Soft tissue tone

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 Assessment/Diagnosis
• Positive findings with • Positive findings with
repeated movements resistive movements
may indicate may indicate a
derangement muscle lesion
• Positive findings with
passive movements
may indicate joint

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 PT Diagnosis
• Musculoskeletal • Derangement
practice pattern? (centralizers vs.
• Acute/subacute/ noncentralizers
chronic?  Anterior
• Postural  Posterior
• Dysfunction  Posterolateral
 Hypomobility  Far lateral
 Soft tissue • Muscle length/
dysfunction strength
• Hypermobility • Myofascial
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 Classification
• Postural
• Derangement
• Dysfunction
• Joint dysfunction
• Muscle lesion
• Ligamentous sprain
• Hypermobility/instability

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 Cervical Derangements
• #s 1-6 are posterior • Goal is to get patient
• #s 1,3,5 no deformity to perform retraction
• #s 1,2 central/symm in sitting throughout
day
• #s 2,4,6 deformity
• May need to utilize
#2 – acute kyphosis
nonweighting
#4 – torticollis retraction and
#6 - torticollis extension,
#5,6 pain below elbow sidebending, rotation

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 Treatment of derangement
• Postural correction
• Exercises in direction of preference
• May begin in weightbearing or non-
weightbearing position
• Recovery of function

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 PT Intervention
• Intervention directed toward patient classification
• Postural syndrome – postural correction
• Derangement – exercises according to direction of
preference
• Dysfunction – passive stretching, soft tissue mobilization
• Adverse neural tension - neuromobilization
• Hypomobility - manual physical therapy
• Hypermobility – cervicial spine stabilization
• Muscle lesion – muscle re-education, therapeutic
exercise
• Manual or mechanical traction

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 Manual Physical Therapy
• Risk vs. Benefit in • PACVP
cervical spine (Rivett, • PAVP
DiFabio) • TVP
• Progression of patient • High velocity thrust
generated forces
(McKenzie)  Safe practice through
Premanipulative testing,
• Grades of mobilization I- Grades of mobilization,
IV (Maitland) Positioning (Meadows),
Component technique
(Hartman)

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 Upper Cervical Spine Examination
• Subjective • Repeated movements –
• Functional questionnaire midcervical
– Neck Disability Index • If no effect:
(NDI) • AROM – upper cervical
• Gait analysis • Passive intervertebral
• Structural exam motion – upper cervical
• AROM - midcervical • Motor performance
 quality of motion • Neurological
 quantity of motion • Palpation

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Examination of upper cervical spine
• Presence of upper cervical pain,
headaches, trauma
• Failure to respond to cervical spine
examination
• Association with TMD

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 Cervical and Vertebrobasilar Tests
• Special tests or tests administered early in the examination?

• Vertebral artery tests

 Sitting, supine, prone
 Rotatory nystagmus test

• Cervical spine stability tests

 Alar ligament
 Sharp-Purser
 Transverse ligament test
 Aspinall

• Sensitivity/specificity
• Screening tools for manual therapy

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 Are provocation tests indicated?
• Special Tests
– Ligamentous Testing
• Vertebral artery test
• Compression
• Distraction
• Foraminal closure
• Alar ligament test
• Transverse ligament test
• Aspinall’s test
• Odontoid fracture test
Sharp-Purser test 36
37
 Questions Regarding
Cervical Spine Stability and
Vertebrobasilar Tests

• Applied as precautionary measures prior

to movement tests or prior to manual
physical therapy intervention?
• Sensitivity/specificity?
• Are provocation tests safe?

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 Examination - AROM

The axis for upper cervical rotation with

mid-cervical spine flexed.

The axis for upper cervical flexion and extension with

with mid-cervical spine rotated.

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The axis for upper cervical sidebending
 Upper Cervical Biomechanics
• Upper cervical flexion measures 10-15
degrees
• Upper cervical extension measures 20-25
degrees
• Upper cervical sidebending measures 5
degrees
• Upper cervical rotation measures 40-45
degrees
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 Examination - PROM

Assessing upper cervical passive flexion

and extension

Assessing C1-C2 rotation

Assessing upper cervical sidebending

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 Examination

Rotatory Nystagmus Test

Distinguishing vertebral artery from vestibular involvement (Patient rotates trunk right while head remains stationary)

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 Assessment of deep neck
flexors
• Strength: Cranio-cervical flexion test
Pressure biofeedback unit inflated to 20 mm,
testing at initial pressure of 22 mm held for 10
seconds (Jull et. al., 2000).
• Endurance: Chin retraction and elevation
of head
Head held 1 inch above the plinth, line drawn
across one of neck folds, PT supports occiput
(Krout and Anderson, 1966, Childs et. al., 2003)
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 Initiation of Guidelines
• Hypomobility vs. Hypermobility
• Vestibular component of treatment
• Cervical component of treatment
• Initiation of standardized outcomes
• Evidence-based
• Retrospective analysis

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 Anticipated Goals/Expected
Outcomes
• Need for outside referral

• Hypomobility vs. hypermobility

• Lengthening vs. strengthening

• Integrated approach based on patient

exam 45
 Cervical Spine Intervention
• Posture

• Patient self-treatment, therapeutic

exercise: stability, mobility, both

• Manual therapy: mobilization,

manipulation, muscle energy technique

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 PT Intervention
• Postural/ergonomic
education • Spine stabilization
• Repeated movements • Muscle balance
in direction of • Traction
preference
• Physical agents
• Manual physical
therapy

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 References

Evidence based practice

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