Cervical Orthopedic Tests Chapters 3 & 4

Tenderness Grading Scale Grade I – mild tenderness to palpation Grade II – mild tenderness with grimace and flinch to moderate palpation Grade III – severe tenderness with withdrawal Grade IV – severe tenderness with withdrawal from noxious stimuli

Cervical Palpation (Anterior) Sternocleidomastoid Carotid arteries Supraclavicular Fossa

Cervical Palpation (Posterior) Trapezius Cervical intrinsic musculature Spinous processes / facet joints

Cervical Range of Motion Take a thorough history to be certain that these motions will not adversely affect the patient. Trauma causing fracture, dislocation, or vascular compromise would be contraindications to performing these tests. Note limited range of motion. Note pain location and character.

Normal Cervical ROM Flexion – 50 degrees or more Extension – 60 degrees or more Lateral flexion – 45 degrees or more Rotation – 80 degrees or more

Cervical Resistive Isometric Testing Evaluate muscle strength and state. Weakness may indicate neurological dysfunction. Pain indicates muscle dysfunction such as a strain.

Muscle Grading Scale 5 – Complete range of motion against gravity with full resistance. 4 – Complete range of motion against gravity with some resistance. 3 – Complete range of motion against gravity. 2 – Complete range of motion with gravity eliminated. 1 – Evidence of slight contractility. 0 – no evidence of contractility.

Vertebrobasilar Circulation Assessment Vascular Insufficiency may be aggravated by positional change in the cervical spine. Assessment of the vertebrobasilar circulation must be done if cervical adjustment or manipulation is to be performed.

Predispositions to Cerebrovascular Accidents Headaches, migraine Dizziness Sudden severe head or neck pain Hypertensive

Predispositions to Cerebrovascular Accidents Cigarette smoking Oral Contraceptives Obesity Diabetes

Cerebrobasilar Testing Positional change in the cervical spine compresses the vertebral artery at the atlantoaxial junction on the side opposite of rotation. In the normal patient, the diminished blood flow does not cause any neurological symptoms, such as dizziness, nausea, tinnitus, faintness, or nystagmus.

Clinical Signs and Symptoms of Cerebrovasular Episodes Vertigo, dizziness, giddiness, light-headedness Drop attacks, loss of consciousness Diplopia Dysarthria

Clinical Signs and Symptoms of Cerebrovasular Episodes Dysphagia Ataxia of gait Nausea, vomiting Numbness on one side of the face Nystagmus

Barre-Lieou Sign Procedure: Patient rotates head from one side to the other. Positive Test: Vertigo, dizziness, visual blurring, nausea, faintness, nystagmus. Structure affected: Vertebral artery on the same side of head rotation. Consider patency of the carotid arteries and the communicating cerebral artery circle.

Barre-Lieou Sign

Vertebrobasilar Artery Functional Maneuver Procedure: Palpate and auscultate the carotid arteries for pulsations and bruits. Instruct the patient to rotate and hyperextend the head.

Vertebrobasilar Artery Functional Maneuver Positive Test: If pulsation or bruits are present at either the carotid or subclavian arteries the test is positive. Structures Affected: It may indicate stenosis or compression of the carotid or subclavian arteries.

Vertebrobasilar Artery Functional Maneuver

Maigne’s Test Procedure: Patient extends and rotates the head and holds that position for 15 – 40 seconds. Repeat on opposite side. Positive Test: Vertigo, dizziness, visual blurring, nausea, faintness, and nystagmus. Structures Affected: Vertebral, basilar, or carotid artery stenosis or compression.

Maigne’s Test

Dekleyn’s Test Procedure: Patient supine, head off table. Instruct pt. to hyperextend and rotate head. Hold 15 to 30 seconds. Repeat opposite. Positive Test: Vertigo, dizziness, visual blurring, nausea, faintness, and nystagmus. Structures Affected: Vertebral, basilar, or carotid artery stenosis or compression.

Dekleyn’s Test

Hautant’s Test Procedure: Pt. Seated, eyes closed, extend arms to front with palms up. Pt. extend and rotate head. Positive Test: Patient loses balance, drops arms, and will pronate the hands. Structures Affected: Vertebral, basilar, or carotid artery stenosis or compression.

Hautant’s Test

Underburg’s Test Procedure: Pt. standing. Close eyes and assess equilibrium. Stretch arms and supinate hands. Then pt. marches in place. Then pt. extends and rotates head while marching. Then opposite side.

Underburg’s Test Positive Test: Patient loses balance, arms drift, hands pronate. Vertigo, dizziness, visual blurring, nausea, faintness, and nystagmus. Structures Affected: Vertebral, basilar, or carotid artery stenosis or compression.

Underburg’s Test

Hallpike’s Maneuver Procedure: Pt. supine with head extended off table. Support head and move it into extension. Then laterally flex and rotate. Hold 15 to 40 seconds. Repeat opposite. Then hang head in free hyperextension.

Hallpike’s Maneuver Positive Test: Vertigo, dizziness, visual blurring, nausea, faintness, and nystagmus. Structures Affected: Vertebral, basilar, or carotid artery stenosis or compression.

Hallpike’s Maneuver

Hallpike’s Maneuver

Clinical Signs and Symptoms of Cervical Strain or Sprain Cervical and upper back pain Cervical and upper back stiffness Cervical and upper trapezius tightness Reduced cervical range of motion Cervical extensor spasm

Differentiating Between Strain and Sprain Cervical strain is an irritation and spasm of the muscles of the cervical spine with or without partial muscle fiber tearing. Cervical sprain is a wrenching of the joints of the cervical spine with partial tearing of its ligaments.

Categories of Strain Mild: Slight disruption of muscle fibers with no appreciable hemorrhage and minimal amounts of swelling and edema.

Categories of Strain Moderate: Laceration of muscle fibers with an appreciable amount of hemorrhage into the surrounding tissues and a moderate amount of swelling and edema. Severe: Complete disruption of the muscle tendon unit, possibly with tearing of the tendon from the bone or a rupture of the muscle through its belly.

Categories of Sprain Mild: Slight tears of a few ligamentous fibers. Moderate: More sever tearing of ligamentous fibers but not complete separation of the ligament.

Categories of Sprain Severe: Complete tearing of a ligament from its attachments. Avulsion: A ligament that attaches to a bone is pulled loose with a fragment of that bone.

O’Donoghue’s Maneuver Procedure: Patient seated. Put the cervical spine through resisted range of motion, then through passive range of motion. Positive Test: Pain during resisted range of motion or isometric muscle contraction signifies muscle strain. Pain during passive range of motion may indicate a sprain of any of the cervical ligaments.

O’Donoghue’s Maneuver Structures Affected: Cervical spinal muscles and/or cervical spinal ligaments. Since resisted range of motion mainly stresses muscles and passive range of motion mainly stresses ligaments, you should be able to determine between strain and sprain or a combination thereof.

O’Donoghue’s Maneuver

Spinal Percussion Test Procedure: Patient seated. Head slightly flexed, percuss the spinous process and associated musculature of each cervical vertebrae with a reflex hammer.

Spinal Percussion Test Positive Test: Local pain may be a fractured vertebra with no neurological compromise. Radicular pain may be a fractured vertebra with neurological compromise or a disc lesion with neurological compromise. A ligamentous sprain could also elicit pain upon percussion of the spinous processes.

Spinal Percussion Test

Soto-Hall Test Procedure: Patient Supine. Press on the patient’s sternum with one hand. With the other hand, passively flex the patient’s head to the chest. Positive Test: Local pain could indicate ligament, muscular, ossous pathology or cervical cord disease. Suspect disc defect with radicular symptoms.

Soto-Hall Test

Rust’s Sign Procedure: A patient with severe injury to the upper cervical spine will grasp the head with both hands to support the weight of the head on the cervical spine. The supine patient will support the head while attempting to rise. Positive Sign: The patient stabilizes the head. It might include slight traction.

Rust’s Sign Structures Affected: This could represent severe muscular strain, ligamentous instability, posterior disc defect, upper cervical fracture, or dislocation.

Rust’s Sign

Cervical Instability Clinical Signs and Symptoms Severe cervical pain. Patient stabilizing the head. Little or no cervical motion. Severe cervical muscle spasm. Upper extremity neurological dysfunction. Lower extremity neurological dysfunction.

Space-Occupying Lesions Clinical Signs and Symptoms Cervical pain. Upper extremity neurological symptoms. Lower extremity neurological symptoms.

Valsalva’s Maneuver Procedure: Have the patient bear down as if defecating and focus the bulk of the stress on the cervical spine. Ask if the patient feels pain and have them point to the location.

Valsalva’s Maneuver Positive Test: Local pain with increased pressure could indicate a space-occupying lesion (e.g. disc defect, mass, osteophyte) in the cervical canal or foramen.

Valsalva’s Maneuver

Dejerine’s Sign Procedure: Patient seated. Instruct them to cough, sneeze, and bear down as if defecating (Valsalva’s maneuver). Positive Test: Local pain or pain radiating to the shoulders or upper extremities indicates an increase in intrathecal pressure. Structures Affected: Space-occupying lesion.

Cervical Neurological Compression and Irritation Clinical Signs and Symptoms Cervical pain. Upper extremity radicular pain. Loss of upper extremity sensation. Loss of upper extremity reflexes. Loss of upper extremity muscle strength.

Foraminal Compression Test Procedure: Patient seated. Exert strong downward pressure on the head. Repeat with b/l rotation. Positive Test: Local pain may indicate foraminal encroachment without nerve root pressure or apophyseal capsulitis. Radicular pain may indicate pressure on a nerve root.

Foraminal Compression Test

Jackson’s Compression Procedure: Laterally flex the head and exert strong downward pressure. Perform b/l. Positive Test: Local pain may indicate foraminal encroachment without nerve pressure or apophyseal joint pathology. Radicular pain may indicate pressure on a nerve root.

Jackson’s Compression

Spurling’s Test Procedure: Laterally flex the patient’s head and gradually apply strong downward pressure. If no pain is elicited, put the patient’s head in a neutral position and deliver a vertical blow to the uppermost portion of the patient’s head.

Spurling’s Test Positive Test: Local pain indicates facet joint involvement. Radicular pain indicates nerve root pressure.

Spurling’s Test

Maximum Foraminal Compression Test Procedure: Have the patient approximate the chin to the shoulder and extend the head. Perform b/l.

Maximum Foraminal Compression Test Positive Test: Pain on the side of rotation with a radicular component may indicate nerve compression. Local pain with no radiculopathy may indicate apophyseal joint pathology on the side of rotation. Pain opposite of rotation indicates muscular or ligamentous strain.

Maximum Foraminal Compression Test

Shoulder Depression Test Procedure: Apply downward pressure on the shoulder while laterally flexing the patient’s head to the opposite side.

Shoulder Depression Test Positive Test: Local pain on the side being tested indicates shortening of the muscles, muscular adhesions, muscle spasm, or ligamentous injury. Radicular pain may indicate compression of the neurovascular bundle or thoracic outlet syndrome. Pain on the opposite side indicates a decreased foraminal space, facet pathology, or disc defect.

Shoulder Depression Test

Distraction Test Procedure: Grasp beneath the mastoid processes and press up on the patient’s head. This removes the weight of the patient’s head on the neck.

Distraction Test Positive Test: If local pain increases, suspect muscle strain, spasm, ligamentous sprain, or facet capsulitis. Relief of radicular pain indicates either foraminal encroachment or a disc defect.

Distraction Test

Shoulder Abduction Test (Bakody’s Sign) Procedure: The patient should abduct the arm and place the hand on top of the head. Positive Test: A decrease or relief of the patient’s symptoms indicates a cervical extradural compression problem (i.e. herniated disc, epidural vein compression, or nerve root compression).

Shoulder Abduction Test (Bakody’s Sign)