Cervical Spine Orthopedic Tests

Question 2

What are the most common conditions of neck pain?

Answer 2

• Mobility problems
• Neck pain with radiating symptoms
• Motor control problems
• Headaches
• Combinations

Question 3

What are the two types of provocative tests for neck pain?

Answer 3

• Stretch Tests
• Compression Tests

Question 4

What is the purpose of testing the unaffected side first in neck pain assessments?

Answer 4

To establish a comparison of results with the affected area.

Question 5

What follow-up questions should be asked when pain is a finding in neck assessments?

Answer 5

• Where is the pain?
• What kind of pain?
• Rate (quantify) the pain?
• Does the pain radiate?

Question 6

What is the normal range of motion for cervical flexion?

Answer 6

The patient should be able to touch the sternum without pain.

Question 7

What does a cervical extension evaluation involve?

Answer 7

The patient looks up, aiming the face parallel with the ceiling, and should get within 10 degrees of parallel without pain.

Question 8

What does the cervical rotation evaluation assess?

Answer 8

The amount of available cervical spine rotation and lateral flexion.

Question 9

What does the Active Supine Occipito-Atlantal Cervical Flexion test differentiate?

Answer 9

It helps differentiate between upper and lower cervical dysfunction.

Procedure:
• Practitioner passively rotates the patient’s head as far as possible to patient’s
comfort
• Instruct patient to bring their chin to their chest
• 20 degrees of occipital flexion is considered normal

Interpretation:
• If the patient can successfully nod their head 20 degrees, the lower cervical spine is most likely responsible for the restriction
• If the patient cannot nod their head 20 degrees, the upper cervical spine is most likely responsible for the restriction

Question 10

What is in the Occipito-Atlantal test?

Answer 10

This test is used when a cervical rotation restriction is identified and helps to differentiate between upper and lower cervical rotation dysfunction.

Procedure:
• Practitioner passively flexes the cervical spine maximally and supports the patient’s head in this position
• Instruct the patient to rotate head to one side
• Rotation should be 45 degrees
• Repeat test on other side

Interpretation:
• Pain during the first 45 degrees is indicative of upper cervical involvement
• If the patient can successfully rotate their head 45 degrees, the lower cervical spine is most likely responsible for the restriction
• If the patient cannot rotate their head 45 degrees, the upper cervical spine is most likely responsible for the restriction
• Subjects suffering from headaches with C1-C2 dysfunction have an average of 17° less
rotation.

Question 11

What is indicated if a patient cannot nod their head 20 degrees in the Occipito-Atlantal test?

Answer 11

The upper cervical spine is most likely responsible for the restriction.

Question 12

What does the Cervical Flexion Rotation Test evaluate?

Answer 12

It helps differentiate between upper and lower cervical rotation dysfunction.

Question 13

What does pain during the first 45 degrees of rotation indicate in the Cervical Flexion Rotation Test?

Answer 13

Upper cervical involvement.

Question 14

What is the significance of a 17° less rotation in subjects suffering from headaches?

Answer 14

It indicates C1-C2 dysfunction.

Question 15

What does the O’Donoghue Maneuver test for?

Answer 15

It helps identify muscle strain versus ligamentous sprain.

Procedure:
• Patient is sitting
• Patient performs active range of motion, examiner makes note of any painful motions
• Examiner then moves the patient’s head passively through each range of motion
• Examiner make note of any painful motions
• The patient maintains head in a neutral position while examiner applies overpressure in all three planes of motion forcing isometric contractions

Interpretation of Findings:
• Pain experienced during active & resisted range of
motion but NOT during passive ROM = muscle strain
• Pain experienced during passive range of motion = ligamentous sprain

Question 16

What does pain experienced during active and resisted range of motion but not during passive ROM indicate?

Answer 16

Muscle strain.

Question 17

What does pain during passive range of motion indicate?

Answer 17

Ligamentous sprain.

Question 18

What is the procedure for the Cervical/Axial Compression Test?

Answer 18

The clinician applies axial compression downward on the head with the head in neutral.

Procedure:
• Patient is seated
• Patient is looking forward
• The clinician applies axial compression downward on the head with the head in neutral.

Interpretation of Findings:
• Positive (+) = radiating pain into the arm(s) or local pain in the cervical spine
• Radiating symptoms are indicative of nerve root compression due to foraminal stenosis, osteophytes; a space occupying lesion (i.e. herniated disc, fracture, tumor).
• Local cervical spine symptoms are indicative of facet encroachment.

Question 19

What does a positive result in the Cervical/Axial Compression Test indicate?

Answer 19

• Radiating pain into the arm(s)
• Local pain in the cervical spine

Question 20

What does a positive finding in the Foraminal Compression Test indicate?

Answer 20

Nerve root compression due to foraminal stenosis, osteophytes, or space occupying lesions.

Procedure:
• Patient is seated
• Patient is looking forward
• The clinician laterally flexes the patient’s head towards the side of testing
• The clinician applies axial compression to the head
• The test is then repeated with the head laterally flexed toward the involved
side
Interpretation of Findings:
• Positive = radiating pain into the arm which the head is laterally flexed
towards
• A positive test is indicative of nerve root compression due to foraminal stenosis, osteophytes, space occupying lesion, herniated disc, fracture
• Local neck pain on the side the head is flexed towards is indicative of facet joint encroachment.

Question 21

What is the procedure for the Maximum Cervical Compression Test?

Answer 21

The patient extends, laterally flexes, and rotates towards the side of testing.

Procedure:
• Patient is seated
• Patient is instructed extend, laterally flex, and rotate towards the side of testing.
• The test is performed bilaterally

Interpretation of Findings:
• Positive = Pain on the concave side indicates nerve root (radiating symptoms) or facet involvement (local pain).
• Pain on the convex (muscle stretch) side indicates muscular strain

Question 22

What does pain on the concave side during the Maximum Cervical Compression Test indicate?

Answer 22

Nerve root involvement or facet involvement.

Question 23

What does the Upper Limb Tension Test (ULTT) assess?

Answer 23

It assesses for median nerve entrapment (C5-C7).

Procedure:
1. Scapular depression
2. Shoulder abduction
3. Forearm supination, wrist and finger extension
4. Shoulder external rotation
5. Elbow extension
6. Contralateral side bend
7. Ipsilateral side bend

Interpretation of Findings:
• Positive = a reproduction of the patient’s symptoms, indicative of median nerve entrapment
(C5-C7)

Question 24

What does a positive result in the Cervical Distraction Test indicate?

Answer 24

• Increased pain indicates muscle spasm or sprain/strain
• Relief of pain indicates intervertebral foraminal encroachment or facet capsulitis.

Procedure:
• Patient is seated
• Examiner stands behind patient
• Examiner grasps beneath the mastoid processes and lifts vertically.

Interpretation of Findings:
• This pressure removes the weight of the patient’s head from
the neck.
• Positive:
• Increased pain indicates muscle spasm or sprain/strain.
• Relief of pain indicates intervertebral foraminal encroachment or facet capsulitis.
• Nerve root compression may be relieved, with disappearance of the
symptoms and signs, if the intervertebral foramina are opened or the disc
spaces extended.
• Pressure on the joint capsules of the apophyseal joints is also decreased
by distraction.

Question 25

What clinical tests are used in the cervical radiculopathy cluster?

Answer 25

* Spurling's Test * Upper limb tension test 1/a * Distraction test * Less than 60 degrees of cervical rotation towards involved side

Question 26

What does a positive result in the Jackson’s Cervical Compression Test indicate?

Answer 26

Radiating symptoms into the arm. Procedure: • Patient is seated • The patient rotates the head to the uninvolved side. • The examiner then carefully presses straight down on the head • The test is repeated with the head rotated to the involved side. Interpretation of Findings: • Positive = radiating symptoms into the testing side arm, indicating nerve root compression. • The pain distribution (dermatome) can give some indication of which nerve root is affected. • Nerve root compression can be from a space-occupying lesion, subluxation, inflammatory swelling (radiculitis), exostosis of degenerative joint disease, tumor, or disc herniation.

Question 27

What is the probability decrease in Jackson’s Cervical Compression Test?

Answer 27

65% ## Footnote This test assesses nerve root compression.

Question 28

What position is the patient in during Jackson’s Cervical Compression Test?

Answer 28

Seated Procedure: • Patient is seated • The patient rotates the head to the uninvolved side. • The examiner then carefully presses straight down on the head • The test is repeated with the head rotated to the involved side. Interpretation of Findings: • Positive = radiating symptoms into the testing side arm, indicating nerve root compression. • The pain distribution (dermatome) can give some indication of which nerve root is affected. • Nerve root compression can be from a space-occupying lesion, subluxation, inflammatory swelling (radiculitis), exostosis of degenerative joint disease, tumor, or disc herniation. ## Footnote The test involves head rotation to both involved and uninvolved sides.

Question 29

What indicates a positive result in Jackson’s Cervical Compression Test?

Answer 29

Radiating symptoms into the testing side arm ## Footnote This suggests nerve root compression.

Question 30

What are some causes of nerve root compression?

Answer 30

* Space-occupying lesion * Subluxation * Inflammatory swelling (radiculitis) * Exostosis of degenerative joint disease * Tumor * Disc herniation

Question 31

What is the SP (sensitivity) range for Jackson’s Cervical Compression Test?

Answer 31

86-92% ## Footnote SP indicates the test's ability to correctly identify positive cases.

Question 32

What does a positive Bakody’s Sign indicate?

Answer 32

Cervical nerve root compression Procedure: • While in the seated position, the patient actively places the palm of the affected extremity on top of the head, raising the elbow to a height approximately level with the head Interpretation of Findings: • Positive = The “sign” is present when the radiating pain is lessened or disappears with this maneuver. • A cervical nerve root compression is suggested by a positive Bakody sign • By elevating and upward rotating the scapula, traction of the upper trunk of the brachial plexus and specifically the suprascapular nerve is relieved • Overall, this maneuver decreases stretching of the compressed nerve root. ## Footnote This is assessed by the patient placing their palm on their head.

Question 33

What is the procedure for the Shoulder Abduction Relief Test AKA Bakody’s sign?

Answer 33

Patient actively places the palm of the affected extremity on top of the head ## Footnote The elbow is raised to head level.

Question 34

What occurs in a positive Shoulder Depression Test?

Answer 34

Radicular pain produced or aggravated on the testing side Procedure: • With the patient seated, the examiner laterally flexes the cervical spine away from that shoulder then depresses the patient's shoulder on the affected side Interpretation of Findings: • Positive = radicular pain is produced or aggravated on the testing side. • A positive sign indicates adhesions of the dural sleeves, spinal nerve roots, or adjacent structures of the joint capsule of the shoulder. • Note: The side opposite of testing is being compressed and findings similar to other compression tests could occur. These finding do not indicate a positive test. ## Footnote Indicates adhesions of dural sleeves or spinal nerve roots.

Question 35

What does unusual pain response indicate in the Spinal Percussion Test?

Answer 35

Possible fractured vertebra Procedure: • With the patient seated and the head slightly flexed, the examiner percusses the spinous processes and associated musculature of each of the cervical vertebra with a neurologic reflex hammer Interpretation of Findings: • Positive = unusual pain response • Evidence of localized pain indicates a possible fractured vertebra. • Evidence of radicular pain indicates a possible disc lesion. • Because of the nonspecific nature of this test, other conditions could also elicit a positive pain response. • Ex. A ligamentous sprain will cause pain when the spinous processes are percussed. ## Footnote Localized pain may indicate a disc lesion.

Question 36

What is indicated by the Rust Sign?

Answer 36

Cervical instability • Positive = If the patient spontaneously grasps their head with both hands when lying down or when arising from a recumbent position, indicating cervical instability due to possible sprain, rheumatoid arthritis, fracture, or severecervical subluxation. ## Footnote Patient grasps their head when lying down or arising.

Question 37

What is the procedure for the Valsalva Maneuver?

Answer 37

Patient inhales deeply and holds breath while bearing down abdominally Procedure: • The patient inhales deeply and holds their breath, while bearing down abdominally Interpretation of Findings: • Positive = increased pain caused by increased intrathecal pressure. • Increased intrathecal pressure exacerbates a space-occupying lesion (herniated disc, tumor, osteophytes). • The test should be performed with care and caution because the patient may become dizzy and pass out while or shortly after performing this test because the procedure can block the blood supply to the brain. ## Footnote This increases intrathecal pressure.

Question 38

What does a positive Dejerine Sign indicate?

Answer 38

Aggravation of radiculitis symptoms due to mechanical obstruction Procedure: • Coughing, sneezing, and straining during defecation may aggravate radiculitis symptoms Interpretation of Findings: • This aggravation results from the mechanical obstruction of spinal fluid flow. • Dejerine sign is present when one of the following space occupying lesions exists: herniated or protruding intervertebral disc, spinal cord tumor, or spinal compression fracture. • The course of the radiculitis helps identify the location of the lesion ## Footnote Symptoms may worsen with coughing, sneezing, or straining.

Question 39

What does a positive Lhermitte Sign indicate?

Answer 39

Electric shock sensations down the neck Procedure: • The patient is seated on the examining table • The patient's head is passively flexed Interpretation of Findings: • Positive = • Electric shock sensations down the neck indicates multiple sclerosis • A sharp pain radiating down the spine and into the upper or lower limbs is a positive finding for cord pathology from possible dural irritation, tumor, or dens fracture. ## Footnote This finding suggests multiple sclerosis or cord pathology.

Question 40

What is indicated by a positive Brudzinski Sign?

Answer 40

Flexion of both knees and hips • The patient is in the supine • Examiner passively flexes the patient's head Interpretation of Findings: • Positive = flexion of both knees and hips occurs, indicative of an advanced meningitis infection. ## Footnote This is indicative of advanced meningitis infection.

Question 41

What is the purpose of the Soto-Hall Sign?

Answer 41

To suspect vertebral fracture Procedure: • The patient is placed supine • The examiner places one hand on the sternum of the patient and exerts slight pressure so that no flexion can take place at either the lumbar or thoracic regions of the spine • The examiner places the other hand under the patient's occiput and flexes the head toward the chest Interpretation of Findings: • The test is used primarily when fracture of a vertebra is suspected. • The flexion of the head and neck while preventing flexion of the thoracic spine progressively produces a pull on the posterior spinous ligaments. • Positive = movement of the injured vertebra occurs the patient experiences a noticeable local pain, indicating subluxation, exostoses, disc lesion, sprain or strain, vertebral fracture, or meningeal irritation (an elevated temperature must exist for corroboration). ## Footnote The test assesses for local pain indicating subluxation or irritation.

Question 42

What is the procedure for the Craniocervical Flexion Test?

Answer 42

Patient lies supine with an inflatable pressure sensor under the cervical spine Procedure: • The patient lies supine • An inflatable pressure sensor is placed under the cervical spine. • Towels may be used to keep the head and neck in midrange neutral (two parallel lines: one from forehead to chin and one from tragus of ear to the line of the longitudinal neck). • The pressure device is inflated to 20 mm Hg to “fill in” the lordotic curve of the cervical spine. • While keeping the head/occiput stationary (no pushing down or lifting up), the patient flexes the cervical spine by nodding the head in five graded segments of increasing pressure (22, 24, 26, 28, and 30 mm Hg) and holds each for 10 seconds with 10 seconds rest between each segment. Interpretation: • Positive: is considered if the patient cannot increase pressure to at least 26 mm Hg, is unable to hold a contraction for 10 seconds, uses the superficial neck muscles, or extends the head. ## Footnote The test measures the ability to increase pressure while nodding the head.

Question 43

What indicates a positive result in the Deep Neck Flexor Endurance Test?

Answer 43

Inability to maintain position for at least 39 seconds for males, 29 seconds for females • The patient lies supine • Chin is maximally retracted by the patient • Maintaining chin tucked instruct the patient to lift their head and neck approximately 2 to 5 cm (1 inch) above the examining table. • The examiner places a hand on the table under the patient’s head (occiput). • The examiner watches the skin folds resulting from the chin tuck and neck flexion. As soon as the skin folds separate (due to loss of chin tuck) or the patient’s head touches the examiner’s hand, the test is terminated. Interpretation: • Establish a strength/endurance baseline. Inability to maintain position for at least 39 seconds for males, 29 seconds for females indicates weak deep neck flexor group. ## Footnote Indicates weakness in the deep neck flexor group.

Question 44

What is the patient position for testing deep neck flexors?

Answer 44

Supine, with shoulders in 90 degrees of abduction and external rotation Patient Position: • Supine • Shoulders in 90 degrees of abduction and external rotation and elbows at 90 degrees of flexion • Patient lifts head with the chin tucked (occipital flexion) towards sternum Pressure: • Contact patient’s forehead • Apply A-P pressure ## Footnote Patient lifts head with chin tucked.

Question 45

What is assessed in the testing of the Upper Trapezius?

Answer 45

Patient elevates same side shoulder while head is turned to the opposite side Patient Position: • Seated or prone • Head turned to side opposite of testing • Patient elevates same side shoulder, approximating occiput and acromion process Pressure: • Contact #1 • posterior occiput • Apply P-A and L-M pressure • Contact #2 • Acromion process • Apply S-I pressure (depressing shoulder) ## Footnote Pressure is applied to the posterior occiput and acromion process.

Question 46

What is the Modified Spurling’s?

Answer 46

Procedure: • Patient is seated • Patient is instructed to extend their head • Laterally flex toward the testing side • Compress axially (S-I) • Repeat the procedure to the side of complaint Interpretation of Findings: • Positive = radiating symptoms towards the closed side. • A positive test is indicative of nerve root compression if radiating symptoms are present. • Other common findings = Local pain is indicative of facet encroachment.

Question 47

What is assessed in the testing of the Sternocleidomastoid and Scalene?

Answer 47

Patient Position: • Supine • Shoulders in 90 degrees of abduction and external rotation and elbows at 90 degrees of flexion • Head turned to side opposite of testing • Patient lifts head off table keeping shoulders flat Pressure: • Contact temporal region • Apply A-P and L-M pressure

Question 48

What is assessed in the testing of the Posterolateral Neck Extensors?

Answer 48

Patient Position: • Prone • Shoulders in 90 degrees of abduction and external rotation and elbows at 90 degrees of flexion • Patient looks toward the side of testing Muscles tested in this position: • Right – splenius capitis and cervicis, semispinalis capitis and cervicis, cervical spinal erectors • Left – upper trapezius Pressure: • Contact the posterolateral occiput • Apply L-M and P-A pressure