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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• Structural • AROM• Repeated movements• PROM (PIVM)• Muscle performance

– deep neck flexor strength and endurance, muscle balance tests

• Neurological – dermatomes, myotomes, muscle stretch reflexes, neurodynamic testing

• Palpation• Special 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 with extension• Above testing in

weightbearing• Baseline prior to each

test movement• PDM or ERP• Deviations

• Retraction• Retraction with extension• Above testing in supine• Baseline prior to each

test movement• PDM or ERP• Deviations• Repeated sidebending

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• Decreased• Increased/no worse• Decreased/no better

• Centralized• Peripheralized • Worse• 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 abnormalitiesSkin rollingSkin puckeringToneLigamentous 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 repeated movements may indicate derangement

• Positive findings with passive movements may indicate joint

• Positive findings with resistive movements may indicate a muscle lesion

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PT Diagnosis

• Musculoskeletal practice pattern?

• Acute/subacute/ chronic?

• Postural• DysfunctionHypomobilitySoft tissue

dysfunction• Hypermobility

• Derangement (centralizers vs. noncentralizers

AnteriorPosteriorPosterolateralFar lateral• Muscle length/

strength• 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• #s 1,3,5 no deformity• #s 1,2 central/symm• #s 2,4,6 deformity

#2 – acute kyphosis

#4 – torticollis

#6 - torticollis

#5,6 pain below elbow

• Goal is to get patient to perform retraction in sitting throughout day

• May need to utilize

nonweighting retraction and extension, 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 cervical spine (Rivett, DiFabio)

• Progression of patient generated forces (McKenzie)

• Grades of mobilization I-IV (Maitland)

• PACVP• PAVP• TVP• High velocity thrust Safe practice through

Premanipulative testing, Grades of mobilization, Positioning (Meadows), Component technique (Hartman)

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Upper Cervical Spine Examination

• Subjective• Functional questionnaire

– Neck Disability Index (NDI)

• Gait analysis• Structural exam• AROM - midcervical quality of motion quantity of motion

• Repeated movements – midcervical

• If no effect: • AROM – upper cervical• Passive intervertebral

motion – upper cervical• Motor performance• Neurological• 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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• Special Tests– Ligamentous Testing

• Vertebral artery test• Compression• Distraction• Foraminal closure• Alar ligament test• Transverse ligament test• Aspinall’s test• Odontoid fracture testSharp-Purser test

Are provocation tests indicated?

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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 flexion and extension with with mid-cervical spine rotated.

The axis for upper cervical rotation with mid-cervical spine flexed.

The axis for upper cervical sidebending

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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 upper cervical sidebending

Assessing C1-C2 rotation

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Examination

Rotatory Nystagmus TestDistinguishing 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

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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

• Repeated movements in direction of preference

• Manual physical therapy

• Spine stabilization• Muscle balance• Traction• Physical agents

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References

Evidence based practice