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1

Spurling's Test

The Spurling's test (also known as Maximal Cervical Compression Test and Foraminal Compression Test) is used during a musculoskeletal assessment of the cervical spine when looking for cervical nerve root compression causing Cervical Radiculopathy[

There are different ways described in the literature to perform the Spurling's test. The version that provoked arm symptoms the best was with the neck in extension, lateral flexion and axial compression.

2

Cervical Flexion-Rotation Test

The Cervical Flexion-Rotation Test (CFRT), in contrast to other forms of manual examination, is an easily applied clinical test purportedly biased to assess dysfunction at the C1-C2 motion segment. The C1-C2 motion segment accounts for 50% of the rotation in the cervical spine

In this test procedure, the cervical spine is fully flexed, in an attempt to isolate movement to C1-C2, which has an unique ability to rotate in flexion. Normal range of rotation motion in end range flexion has been shown to be 44° to each side. In contrast, subjects suffering from headache with C1-C2 dysfunction have an average of 17° less rotation.

Patient is relaxed in supine
Examiner fully flexes the cervical spine with the occiput resting against the examiners abdomen
The patient's head is then rotated to the left and the right
If a firm resistance is encountered, pain provoked, and range is limited before the expected end range, then the test is considered positive, with a presumptive diagnosis of limited rotation of C1 on C2

As stated previously, the CFRT has been shown to be negative in subjects with CGH where pain arises from cervical levels other than C1-C2

3

Transverse Ligament Stress Test

Purpose
Test for hypermobility of the atlantoaxial articulation

Technique
The patient is placed in a supine postion with the Therapist supporting the patient's head with the palms and 3rd-5th fingers.
The Therapist then places the index fingers between the occiput and spinous process of C2, so the index fingers are over the neural arch of the C1 vetebra.
The Therapist then lifts the patients head and C1 vetebra anteriorly, without allowing flexion or extension.
The position should be held for 10-20 seconds.
A positive test is the recurrence of symptoms:
Abnormal pupil response
Eye twitching or nystagmus
Soft end feel
Muscle spasm
Dizziness
Nausea
Paresthesia of the lip face or limb
Lump sensation in the throat

4

Cervical Distraction Test

The Cervical Distraction Test is a diagnostic test for the presence of Cervical Radiculopathy

Patient lies supine and the neck is comfortably positioned. Examiner securely grasps the patient's head either by placing each hand around the patient’s mastoid processes, while standing at their head, or place one hand on their forehead and the other on the occiput. Slightly flex the patient’s neck and pull the head towards your torso, applying a distraction force.

A positive test is the reduction or elimination of symptoms with traction
Neural foramen and joint capsules around the facet joints of the cervical spine. The neck extensor muscles are also secondarily observed during this test.

As disc height decreases and bone spurs accumulate, the space for nerves to enter and exit the vertebral canal gets smaller. The decreased space can result in greater pressure on the nerve roots or other innervated structures, causing pain and weakness. With distraction, the joint space is increased to relieve the pressure on the nerve roots, thus decreasing the symptoms.

5

Arm Squeeze Test

This is a new clinical test that may be useful to distinguish between Cervical radiculopathy from other shoulder related pathology

Technique
The examiner stands behind the patient
then squeezes the middle third of the patient's upper arm with thumb (examiner) on patient's triceps while the rest of the fingers is on the patient's biceps
With a moderate compression (5.9 to 8.1kg)
It is positive if the patient reports 3 or higher on VAS with pressure on middle third of upper arm compared with acromioclavicular joint and subacromial area

Positive = Cervical Origin

6

Adsons test (TOS)

Adson's test is a provocative test for Thoracic Outlet Syndrome accompanied by compression of the Subclavian artery by a cervical rib or tightened anterior and middle scalene muscles

Technique
The test can be performed with the patient in either sitting or standing with their elbow in full extension

Procedure

• The arm of the standing (or seated) patient is abducted 30 degrees at the shoulder and maximally extended.

• The radial pulse is palpated and the examiner grasps the patient's wrist.

• The patient then extends neck and turns the head toward the symptomatic shoulder and is asked to take a deep breath and hold it.

• The quality of the radial pulse is evaluated in comparison to the pulse taken while the arm is resting at the patient's side.

• Some clinicians have patients turn their heads away from the side tested in a modified test.

Positive Test

The test is positive if there is a marked decrease, or disappearance, of the radial pulse. It is important to check the patient's radial pulse on the other arm to recognize the patient's normal pulse.

A positive test should be compared with the non-symptomatic side.

There is minimal evidence of its interexaminer reliability according to existing literature. It has been noted to have a specificity ranging from 18% to 87%, and sensitivity of up to 94%. There is little documentation regarding the reliability of the Adson's test.

A problem with the thoracic outlet tests on the whole is that many asymptomatic subjects will test positive, depending how a positive test is defined. In an asymptomatic population, Rayan (1998) found Adson’s to have a false positive rate of 13.5% for diminished/absent pulse but only 2% for neurological symptoms. Plewa (1998) found a comparable false positive rate of 11% for loss of pulse, a higher false positive rate for paresthesia (11%), but a very low rate of pain production (2%). Overall, Adson’s false positive rates were lower than those of either the hyperabduction and costoclavicular tests. Other studies have reported false positive rates (including isolated diminished pulse positives) to range as high as 53% (Rayan 1998) and even 92% (Malanga 2006).

Although, overall, Adson’s test appears to be more useful than the costoclavicular or hyperabduction test, using a diminished radial pulse to determine a positive Adson’s test should be done with caution. Even symptom reproduction during the procedure must be correlated with other findings. At least one retrospective post surgical study fails to identify any “single preoperative diagnostic criterion” for thoracic outlet syndrome (Donaghy 1999).

Rather, it is better to interpret the tests in combination (Nannapaneni 2003, Plewa 1998, Rayan 1998). Rayan (1998) and Nannapaneni et al. (2003) reported sensitivity of 94% using a combination of Adson’s, Eden’s, Wright’s and Roos tests with Tinel’s test or direct compression of the associated nerves. Likewise specificity appears to improve when multiple tests are combined. In Warrens’ study (1987), 58% of subjects given a battery of TOS tests (Adson’s, costoclavicular and hyperabduction) had at least one false positive, and only 2% had more than one test positive. Likewise, Plewa (1998) found that 2 or 3 positive tests dropped the overall false positive rate and improved the specificity.

Unfortunately, most of the studies looking at specificity used asymptomatic patients rather than symptomatic patients with competing diagnoses, which tends to inflate test specificity values. Furthermore, because there is no gold standard to make a TOS diagnosis, most studies use the same orthopedic tests under investigation as part of the reference standard (incorporation bias), inflating the sensitivity values.

7

ROOS

This test is a diagnostic tool used in the identification of Thoracic Outlet Syndrome (TOS). It is also known as the “elevated arm stress test” or "EAST".

Starting postion: [1]

The patient has both arms in the 90° abduction-external rotation position
Shoulders and elbows are in the frontal plane of the chest


Execution:

The patient is to open and close the hands slowly over a 3-minute period


Results if normal:

Only forearm muscle fatigue and minimal distress


Possible symptoms if TOS is present:

gradual increase in pain at neck and shoulder, progressing down the arm
Paraesthesia in forearm and fingers
In case of arterial compression: arm pallor with arm elevated, reactive hyperemia when limb is lowered
In case of venous compression: Cyanosis and swelling
Inability to complete test, and patient drops arms in lap in marked distress, recognized as reproduction of usual symptoms
Reproduction of the usual symptoms that involve the entire extremity!


Possible results if carpal tunnel syndrome is present:

Numbness in first three fingers due to compression of nervus medianus


Possible results in case of cervical disc syndrome:

Pain in neck and shoulder from holding arms elevated but minimal distress in arm or hand.


Possible results in case of orthopedic shoulder problems:

Intolerable symptoms confined to shoulder area