1. Cervical Orthopedic Tests
Chapters 3 & 4

2. 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

3. Cervical Palpation (Anterior)
Sternocleidomastoid
Carotid arteries
Supraclavicular Fossa

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

5. 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.

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

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

8. 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.

9. 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.

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

11. Predispositions to Cerebrovascular Accidents
Cigarette smoking
Oral Contraceptives
Obesity
Diabetes

12. 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.

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

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

15. 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.

16. Barre-Lieou Sign

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

18. 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.

19. Vertebrobasilar Artery Functional Maneuver

20. 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.

21. Maigne’s Test

22. 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.

23. Dekleyn’s Test

24. 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.

25. Hautant’s Test

26. 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.

27. 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.

28. Underburg’s Test

29. 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.

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

31. Hallpike’s Maneuver

32. Hallpike’s Maneuver

33. 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

34. 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.

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

36. 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.

37. 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.

38. 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.

39. 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.

40. 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.

41. O’Donoghue’s Maneuver

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

43. 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.

44. Spinal Percussion Test

45. 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.

46. Soto-Hall Test

47. 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.

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

49. Rust’s Sign

50. 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.

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

52. 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.

53. 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.

54. Valsalva’s Maneuver

55. 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.

56. 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.

57. 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.

58. Foraminal Compression Test

59. 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.

60. Jackson’s Compression

61. 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.

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

63. Spurling’s Test

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

65. 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.

66. Maximum Foraminal Compression Test

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

68. 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.

69. Shoulder Depression Test

70. 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.

71. 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.

72. Distraction Test

73. 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).

74. Shoulder Abduction Test (Bakody’s Sign)