MUSCULOSKELETAL EXAMINATION OF THE CERVICAL SPINE (P2; Objective assesment)

If the patient is supporting the head and neck during the history and observation and is afraid to move the head what sign does this indicate?

Rust’s Sign

indication of cervical instability dt fracture or ligamentous injury

OI GUIDELINES: (skim thru)

• Manner of arrival

• Mental status (lethargic, alert, coherence)  

• Facial expression/wincing (indication of irritable pain)

• Protective posturing 

  •  Rust’s Sign

• Attachments and assistive devices

  • Cervical collar (can be hard or soft; for fx, instability, sprain, strains) 

• Signs of inflammation

• Trophic skin changes 

  • Especially on the distal extremity if myotomes and dermatomes are affected 

• Deformities, asymmetries, deviation

  • Cervical Lordosis = poor postural habits (PA) 

True or False

Abnormalities in one area frequently affect another area. For example, excessive thoracic kyphosis may cause a “poking” chin (cervical spine is in extension) to compensate for the thoracic deformity and to maintain the body’s center of gravity centered beneath the base of support.

FALSE:

Abnormalities in one area frequently affect another area. For example, excessive lumbar lordosis may cause a “poking” chin (cervical spine is in extension) to compensate for the lumbar deformity and to maintain the body’s center of gravity centered beneath the base of support.

Normal Value for cervical lordosis

30° to 40°

Stiff neck; muscle spasm, tightness, or prominence of the sternocleidomastoid muscle causing lateral flexion to affected side and opposite side rotation; can be congenital or acquired

Torticollis

In Klippel-Feil syndrome which cervical vertebra are most commonly affected by congenital fusion?

C3-5

Acute torticollis can also be caused by what type of neck problem?

head is laterally flexed away from painful side

Disc problems can cause acute torticollis

A habitual poking chin can result in adaptive shortening of what muscles?

Occipital muscles

True or False:

A poking chin causes the cervical spine to change alignment resulting in increased comprehensive stress of the facet joints and anterior discs and other anterior elements

False:

A poking chin or military posture causes the cervical spine to change alignment resulting in increased comprehensive stress of the facet joints and posterior discs and other posterior elements

A poking chin may also lead to weaknesses in what group of muscles?

Deep neck flexors

What muscles are weak in an upper crossed syndrome?

• deep neck flexors

• rhomboids

• serratus anterior

• lower trapezius.

What muscles are tight in an upper crossed syndrome?

• pectoralis major and minor

• upper trapezius

• levator scapulae

True or False:

Torticollis may be habitual, in other words, the patient always goes back to this posture.

True

Habitual posture may result from postural compensation, weak muscles, hearing loss, temporomandibular joint problems, or wearing of bifocals or trifocals.

Which shoulder is lower, dominant side or non dominant side?

Dominant side should be slightly lower

emphasis on slightly

Which shoulder is lower, injured side or non non-injured side?

Non-injured side is lower

the injured side may be elevated to provide protection or because of muscle spasm

Rounded shoulders may be the result of or the cause of a poking chin, also causes the:

• scapulae to protract or retract?

• humerus to laterally or medially rotate?

• Anterior/Posterior structures to lengthen?

• Anterior/Posterior structures to tighten?

Rounded shoulders may be the result of or the cause of a poking chin, also causes the:

• scapulae to protract

• humerus to medially rotate

• Posterior structures to lengthen

• Anterior structures to tighten

Atrophy of the deltoid is caused by which nerve palsy?

Axillary nerve palsy (C5, C6 nerve root)

True or False:

Observing patient facial expression is important to give the examiner an idea on how much the patient is objectively suffering.

FALSE:

Observing patient facial expression is important to give the examiner an idea on how much the patient is subjectively suffering.

Patient with cervical spine injury describe findings:

• Head tilted towards pain or away from pain?

• Head rotated towards pain or away from pain?

• Face tilted upward or downward?

Patient with cervical spine injury describe findings:

• Head tilted away from pain

• Head rotated away from pain

• Face tilted upward

hysterical patient describe findings:

• Head tilted towards pain or away from pain?

• Head rotated towards pain or away from pain?

• Face tilted upward or downward?

hysterical patient describe findings:

• Head tilted towards pain

• Head rotated towards pain

• Face tilted downward

True or False:

Referred pain from conditions, such as spondylosis, tends to occur in the shoulder and arm rather than the neck.

True:

Common areas for spondylosis are c4-5, c5-6 and c6-7

nerve roots c5, 6 and 7 have dermatome distributions to the shoulder and arm

True or False:

when examining the cervical spine it must include the neck, upper thoracic spine, upper ribs, and both upper limbs.

True:

Many of the symptoms that occur in an upper limb originate from the neck. Unless there is a history of definite trauma to a peripheral joint, an upper limb scanning examination must be performed to rule out problems within the neck.

If the patients movement is aberrant or uncontrolled during AROM examination, what is this called?

Cervical movement control dysfunction

Female patients tend to have a greater cervical active ROM than males, except in what movement?

Flexion

True or False:

ALL cervical motion available range decreases with age.

False:

All except rotation at C1-C2 decreases, rotation may increase.

True or False:

The movements should be done in a particular order so that the most painful movements are done first, so the painful portion of the examination finishes faster.

False:

The movements should be done in a particular order so that the most painful movements are done last, and no residual pain is carried over from the previous movement.

True or False:

In the very acute cervical, only movements that give the most information are done in order to prevent exacerbation of symptoms.

True

If the symptoms are relieved in neutral position, is the condition irritable or nonirritable?

nonirritable

If the symptoms are not relieved in neutral position, is the condition irritable or nonirritable?

Irritable

movements may be restricted depending on the intensity of the symptoms.

True or False:

In AROM and PROM, if the patient is able to hold the end range position, the symptoms would not be considered severe

True

True or False:

If patient cannot hold end range position, we can apply overpressure to determine what causes this.

False:

If the patient cannot hold the end range position, any symptoms would be considered more severe and overpressure should not be applied

Which combination of movements can cause the vertebral artery to be compressed ?

rotation, side flexion, and extension

Rotation alone can also cause compression

During flexion, _______ occurs in the upper cervical spine, whereas _______ occurs in the lower cervical spine.

During flexion, nodding occurs in the upper cervical spine, whereas flexion occurs in the lower cervical spine

True or False:

Movement can occur between C2 and C7 without affecting the other vertebrae

False:

Movement can occur between C1 and C2 without affecting the other vertebrae

for C2 to C7, if one vertebra moves, the ones adjacent to it will also move.

ROM values for cervical spine (follow AAOS):

You ask a patient to nod to test the upper cervical spine (C0-C2), electric shock sensation down the neck, what sign is this called?

Lhermitte sign

indicates severe pathology

Maximum ROM for forward flexion of the lower cervical spine is?

80° to 90°

True or False:

For flexion the extreme of ROM is normally found when the chin is able to reach the chest with the mouth closed; up to two finger-widths between chin and chest is considered abnormal.

False

For flexion the extreme of ROM is normally found when the chin is able to reach the chest with the mouth closed; up to two finger-widths between chin and chest is considered normal.

If the deep neck flexors are weak what muscle initiates flexion?

Sternocleidomastoid

causing the jaw to lead the movement, not the nose, because the SCM causes the chin to initially elevate before flexion occurs

In flexion, the intervertebral disc _______ posteriorly and _______ anteriorly

In flexion, the intervertebral disc widens posteriorly and narrows anteriorly

The intervertebral foramen is how many percent larger on flexion than on extension?

20% to 30% larger

The vertebrae shift ________ in flexion and ________ in extension

The vertebrae shift forward in flexion and backward in extension

True or False:

the mastoid process moves away from the C1 transverse process on flexion and moves toward it on extension.

False:

the mastoid process moves away from the C1 transverse process on flexion and extension.

If there is a prominent spinous process of the axis on flexion, what does this indicate?

Forward subluxation of the atlas

Sharp-Purser test to test for that

If serious symptoms arise (e.g., tingling in the feet, loss of balance, drop attack) during upper cervical extension, this indicates what?

Spinal cord compression or Vertebrobasilar dysfunction.

Extension, or backward bending of the cervical spine, is normally limited to how many degrees

70°

Side, or lateral, flexion is approximately how many degrees to the right and left

45° (AAOS)

Normally, rotation is __________ right and left, and the chin does not quite reach the plane of the shoulder

Normally, rotation is 60° right and left, and the chin does not quite reach the plane of the shoulder

True or False:

Rotation and side flexion always occur together (coupled movement) but not necessarily in the same direction.

True

refresher: C0-2 & C7-T1 opposite directions; C2-7 same directions

Most of the rotation occurs between C1 and C2 If the patient can rotate _____________, then it is unlikely that the C1/C2 articulation is at fault

40° to 50°

If, however, side flexion occurs early to allow full motion, C1–C2 is probably involved

True or False

If, in the history, the patient has complained that repetitive movements or sustained postures have caused problems, not only should the specific movements be performed, but they should be either repeated several times or sustained to see if the symptoms are exacerbated.

True:

movement restrictions and possible causes:

True or False:

If patient cannot complete AROM, and no overpressure can be tested, PROM can be done in supine

True

True or False:

The passive ROM with the patient supine is normally greater than the active and passive ROM with the patient sitting

True

When doing passive flexion with overpressure, if pain is felt in the lower extremities, it may indicate a lower-extremity radiculopathy of one of the lower limb peripheral nerves as the movement stretches the dura

What test is this?

Lindner test

passive flexion + overpressure + second hand on sternum to prevent thoracic flexion.

What test is this?

Soto-Hall test

basically linder test + second hand on sternum to prevent thoracic flexion.

Normal endfeel of all cervical spine movements

Tissue stretch

Resisted Isoms (MMT) basically know ur moina 😅

Whole pic wont fit so go to the next card

After the resisted isometric movements to the cervical spine have been completed, what is performed to rule out obvious pathology in the extremities?

Peripheral joint scanning

TMJ examination:

Pain or tenderness, especially on closing the mandible, usually indicates?

Posterior Capsulitis

Myotomes (lite version)

Myotomes Pro Max

When testing myotomes the contraction should be held for at least how many seconds?

5 seconds

SENSORY ASSESSMENT overview

• sensory scanning examination →  gross sensory assessment 

• % sensory deficit as to what senses in what areas 

• indicate devices used during testing

• Done on the pt’s head and face

Instruments for sensory testing (Superficial senses)

• pinwheel

• pin

• cotton batting

• brush

Reflex testing to test for UMN / LMN lesion:

• Biceps (C5-C6)

• Triceps (C7-C8)

• Brachioradialis (C5- C6)

UMN lesion = Hyperreflexia

LMN lesion = Hyporeflexia

Identify the sign:

• PT holds pt’s middle finger and briskly flicks the distal phalanx 

• (+) if IP joint of the thumb of same hand flexes or abducts

Hoffman Sign (UMN Lesion)

Identify the sign:

• Pathological reflex

• PT rapidly taps near the styloid process at the wrist 

• (+) finger flexion and slight elbow extension 

Inverted Supinator Sign (Inverted Brachioradialis Jerk) (UMN Lesion)

Multiplanar Activities of Neck (Functional Assessment):

• Breathing

• Swallowing

• Looking up to the ceiling

• Looking down at the belt buckle or shoes

• Shoulder check

• Tuck chin in

• Poke chin out

• Neck Strength 

True or False:

Normally when breathing, gulping or gasping can be occasionally heard.

False:

unlabored breathing should be seen with the mouth closed. There should be no gulping or gasping.

At least how many degrees of neck extension is usually necessary for everyday activities.

40° to 50°

If this range is not available, the patient will bend the back or the knees, or both, to obtain the desired range.

when looking down at belt buckle or shoe laces at least how many degrees of neck flexion is necessary?

60° to 70°

If this range is not available, the patient will flex the back to complete the task.

At least how many degrees of neck rotation is needed for shoulder checking?

60° to 70°

If this range is not available, the patient will rotate the trunk to accomplish this task

When you ask the patient to tuck their chin, what are the respective movements of the upper and lower cervical spine?

Upper cervical flexion

Lower cervical extension

When you ask the patient to poke their chin out, what are the respective movements of the upper and lower cervical spine?

Upper cervical extension

Lower cervical flexion

A male football player, who plays as an offensive lineman and weighs 120 kg, is concerned about the risk of neck injury. How much force (in kg) does his neck need to generate to minimize the risk of injury?

36 kg of force

In athletes, neck strength should be approximately equivalent to 30% of body weight to decrease chance of injury

SPECIAL TESTS For Neurological Sx

• Foraminal Compression (Spurling’s) Test 

• Maximum Cervical Compression Test 

• Jackson’s Compression Test 

• Distraction Test 

• Bakody’s Test (C4-C5 affectation)

• Upper Limb Tension Test / Elvey Test

Identify the test and what it’s for:

Foraminal Compression (Spurling) Test

• Pt side flexes neck on affected side 

• PT pushes straight down 

• 3 Stages: 

  • Head in neutral 

  • Head in extension 

  • Head in ext and rotation 

• (+) replication of sx 

If during the spurling test:

• If pain is felt on opposite side

• (+) muscle spasm (tension myalgia or whiplash)

What sign is this?

Reverse Spurling Sign

Identify the test and what it’s for:

Jackson Compression Test (testing nerve root compression)

• Pt rotates head to one side 

• PT punishes straight down 

• (+) radiation of pain to the arm

Identify the test and what it’s for:

Cervical Distraction Test (relieve sx of nerve root compression)

• Pt in sitting/supine position 

• Place one hand around the occiput and one hand under the chin 

• Slowly lift pt’s head 

• (+) relief or reduction of pain

Identify the test and what it’s for:

Shoulder abduction / Bakody’s Test (C4-C5 affectation)

• Pt is sitting or supine 

• PT passively or pt actively elevates arm through abduction until it rests on top of head 

• (+) Bakody’s Sign if relief occurs 

wat dis

Maximum Cervical Compression Test (nerve root/VBI)

• Pt in sitting position, laterally flex and rotate head to same side (add extension for more compression) 

• (+) if pain radiates to arm (on compressed side)

• pain on the convex side indicates muscle strain

• held for 20 to 30 seconds to elicit symptoms of VBI

Upper Limb Neurodynamic / Tension Test 1-4 or Elvey Test:

ULTT  A / ULNT 1 nerve bias = ?

ULTT  B/ ULNT 2 nerve bias = ?

ULTT  C/ ULNT 3 nerve bias = ?

ULTT  D/ ULNT 4 nerve bias = ?

ULTT  A / ULNT 1 nerve bias = Median nerve, anterior interosseous nerve, C5, C6, C7

ULTT  B/ ULNT 2 nerve bias = Median nerve, musculocutaneous nerve, axillary nerve

ULTT  C/ ULNT 3 nerve bias = Radial nerve

ULTT  D/ ULNT 4 nerve bias = Ulnar nerve, C8 and T1

Identify which ULNT/ULTT is which:

A. ULTT  A / ULNT 1

B. ULTT  B/ ULNT 2

C. ULTT  C/ ULNT 3

D. ULTT  D/ ULNT 4

ehhh watch the vid for procedure so long eh.

Special Tests for Instability

• Sharp-Purser Test 

• Transverse Ligament Stress Test 

• Lateral Shear Test 

• Alar Ligament Stress Test

Identify the test and what it’s for:

Sharp-Purser Test (Atlanto-axial instability)

• Extreme caution is required 

• PT places one hand on forehead, and one on spinous process of C2

• Pt flexes the head while PT applies posterior pressure on forehead 

• (+) sliding back of the head (sublaxation) 

Identify the test and what it’s for:

Lateral (Transverse) Shear Ligament Test

Instability of atlanto-axial articulation (odontoid dysplasia)

• Pt in supine 

• PT puts radial side of 2nd MCP joint to transverse process of atlas and othe MCP joint on opposite transverse process

• PT pushes it together 

• Normally painful 

• The test can also be used to test other levels of the cervical spine

Identify the test and what it’s for:

Lateral Flexion Alar Ligament Stress Test (Alar ligament instability)

• Pt in supine with head in neutral position 

• PT stabilizes axis with wide pinch grip around spinous process and lamina

• PT side flexes the head and axis 

• (+) if abnormal side flexion occurs 

Special Test for Vascular Problems

Vertebral Artery (Cervical Quadrant Test)

Test? wat for?

VBI Test or Cervical Quadrant Test

• Pt in supine 

• PT extends and side flexes pt’s head, then rotate to same side  hold for 30 secs 

• (+) provoking referred sx if opposite artery is affected 

• (+) dizziness or nystagmus (nerve compression) 

Upper brachial plexus injury (C5-C6); Muscles of the shoulder region and elbow are affected; sensation of the radial surface of forearm, arm, and deltoid are affected   

What palsy?

Erb-Duchenne Paralysis / Palsy

• Atrophy and weakness of muscles of forearm, hand, and triceps (distal extremity changes) 

• Functionless hand

• sensory loss on ulnar side of forearm and hand

What palsy?

Klumpke (Dejerine- Klumpke) Paralysis / Palsy

Brachial Plexus Birth Palsy is present in how many percent of births?

0.1 to 0.4%

Brachial Plexus Birth Palsy usually fully recovers by how many months?

2 months

Uncured until 3 months: 

• Decreased strength and ROM in UE 

Palpation is usually done in what position?

Supine/Prone

Take not of these things in Palpation:

• Skin temp and texture 

• Muscle tone, spasm, guarding, flaccid paralysis 

• Tenderness

• Mobility of the spinous process

• tightness/contracture = stretching 

• Taut bands, nodules, trigger points = massage

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