Cervical Examination: Difference between revisions

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=== Neurologic Assessment <br>  ===
=== Neurologic Assessment <br>  ===
• A neurological examination should be performed if the patient reports numbness or tingling in the back, shoulder, or more distal upper extremities, or if the patient has focal weakness that would indicate nerve involvement.(1)<br>• '''Reflexes'''(2)<br>o C5 – biceps<br>o C5 – C6 – brachioradialis<br>o C7 – triceps<br>• '''Manual muscle testing '''<br>o <u>Elbow</u><br>• Flexion (C5,C6)<br>• Extension (C7)<br>o <u>Shoulder </u><br>• Flexion (C5)<br>• Extension (C6, C7, C8)<br>• Abduction (C5)<br>o <u>Wrist</u><br>• Flexion (C6 – 7)<br>• Extension (C6 – 7)<br>o <u>Finger</u><br>• Flexion (C7 – C8)<br>• Extension (C7 – C8)<br>• Abduction (T1)
<br>• '''Sensory examination'''<br>o C3 – Occiput<br>o C4 – Supraclavicular space<br>o C5 – Anterior shoulder <br>o C6 – Lateral shoulder<br>o C7 – Posterior arm<br>o C8 – Phalanxes 4 – 5<br>o T1 – Medial arm and axilla
<br>• '''Cranial Nerve Assessment'''(3)<br>o <u>Vestibular and Optic cranial nerve screen for cranial nerves 2,3,4,6 and 8</u><br>• Snellen Eye Chart to test visual acuity<br>• Test each eye separately (covering the untested eye); test at a distance of 20 feet. O’Sullivan, Chapter 8, Examination of motor function<br>• Pupillary reaction, (constriction) is tested by shining a light in the left eye and right eye. If there is an absence of constriction this indicates abnormal function of the optic or oculomotor nerve.<br>• Extraocular movements are tested by asking the patient to follow a moving finger in a horizontal, vertical and horizontal plane. If they eyeball deviates from it’s normal conjugate position, eye movements are impaired or the patient reports double vision, there is dysfunction of the oculomotor, trochlear and/or abducens nerve(s).<br>o <u>Trigeminal Nerve</u><br>• Sensory: Test noxious and light touch sensations on forehead, cheeks and jaw of the patient. Loss of facial sensations or numbness are reported with a trigeminal nerve lesion<br>• Motor: Test the muscles of mastication by asking the patient to clench their teeth. Weakness, wasting of muscles or unilateral jaw deviation indicate a trigeminal nerve lesion.<br>o <u>Facial Nerve</u><br>• Facial expression is tested by asking the patient to raise eyebrows, frown, show teeth, smile, close eyes tightly and puff out both cheeks. <br>• Paralysis is indicated by the patient’s inability to close eye, drooping corner of the mouth or difficulty with speech articulation.<br>o Unilateral LMN: Bell’s Palsy (Peripheral nerve injury)<br>o Bilateral LMN: Guillain-Barre<br>o Unilateral LMN: Stroke<br>o <u>Glossopharyngeal and Vagus and Hypoglossal nerve</u><br>• Listen to voice quality and articulation<br>• Dysphonia: Hoarseness denotes vocal cord weakness; nasal voice quality indicates palatal weakness.<br>• Dysarthria: Poor speech articulation.<br>o <u>Spinal Accessory Nerve</u><br>• Have the patient shrug both shoulders upward against resistance. An inability to shrug bilateral shoulders upward against resistance may indicate a lesion to the spinal accessory nerve.<br><br>


=== Movement Testing  ===
=== Movement Testing  ===

Revision as of 21:59, 17 March 2011

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Subjective[edit | edit source]

Patient Intake[edit | edit source]

  • Self‐report
  • Performance‐based outcome measures
  • Region‐specific historical examination

Special Questions
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  • Red Flags
  • Yellow Flags

Investigations
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  • Radiological Considerations

Objective[edit | edit source]

Observation[edit | edit source]

  • Posture
  • o Observe the patient’s posture in standing and sitting. As a part of the examination, postural deviations can be corrected to determine the effect on the patient’s signs and symptoms.
    o Common postural deviations:
    • Protracted cervical spine or forward head posture
    • Protracted shoulder girdle and rounded shoulders
    • Upper Thoracic Spine
    • Kyphotic or Flexed
    • Lordotic or Extended
    • Normal
    • Middle Thoracic Spine
    • Kyphotic or Flexed
    • Lordotic or Extended
    • Normal

  • Movement Patterns

Functional Tests
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1. Cervical AROM (1)
a. Prior to movement testing the examiner asks the patient about baseline symptom location and intensity. The examiner notes any change in location or intensity during the testing and where in the motion they occur.
b. The examiner should assess for the presence of symptom centralization and peripheralization during testing. Repeated motions may be utilized as part of this assessment.
c. Neck flexion, extension, rotation and side-bending can be measured with an inclinometer
d. All cervical AROM tests performed with the patient in seated in an upright posture
e. Inclinometer cervical ROM measurements have exhibited reliability coefficients ranging from 0.66 to 0.84 (ICC).
f. A universal goniometer is used to measure cervical rotation if measured in sitting.
g. Passive overpressure may be applied at the end of active motion to assess for pain response and end-feel.
h. Combined motions:
• Upper cervical flexion and lower cervical extension is assessed with cervical retraction.
• Upper cervical extension with lower cervical extension is assessed with cervical protraction.
• The cervical quadrant involves combined cervical extension with ipsilateral rotation and sidebending.
2. Cervical and Thoracic Segmental Mobility(1)
a. The patient is positioned in prone. Cervical and thoracic spine segmental mobility and pain response are assessed.
b. The examiner contacts each cervical spinous process with the thumbs. The examiner applies an oscillatory posterior to anterior force.
c. The examiner can assess mobility unilaterally by performing the same procedure over the cervical articular pillar on each side.
d. The examiner assesses for pain provocation at each segment.
e. The mobility of the segments is judged to be normal, hypermobile, or hypomobile. Interpretation of mobility is based on the clinician’s perception and experience.
f. Psychometric data for combined pain provocation and mobility assessment:
• Sensitivity = 0.82 (negative Likelihood Ratio = 0.23)
• Specificity = 0.79 (positive Likelihood Ratio = 3.9)
g. Pain ICC = 0.42 – 0.79 (For patients who have cervical neck pain)
h. Presence of upper cervical Joint dysfunction in patients with headaches ICC = 0.78 – 1.0.
3. Passive OA Joint testing(flexion/extension)
a. Patient positioned in supine with head on or off the treatment table
b. Therapist is in standing at the head of the patient
c. Motion testing (Right OA joint)
• Rotate head 20 – 30 to right side to orient the right facet into the sagittal plane
• Translate occiput anteriorly on the superior facet of C1 to asses for OA extension restriction
• Translate the occiput posteriorly to assess for OA flexion restriction.
• Repeat to the Left side.
4. AA Mobility Testing (Cervical Rotation in Flexion)
a. Cradle head with both hands
b. Contact the posterior aspect of C1 with finger tips
c. Flex cervical spine
d. Assess amount of rotation to each side
e. Maintain flexion while rotating


Palpation[edit | edit source]

  • supine
  • o Palpate bilateral sternoclavicular joints for mobility assessment or tenderness.
    o Palpate acromioclavicular joint for mobility assessment or tenderness.
    o Palpate suboccipital muscles, upper trapezius, levator scapula and pectoralis minor to assess shortness or   tenderness.

  • prone
  • o Central and peripheral Cervical and Thoracic Spine
    o Palpate ribs 1 – 7 of the upper and mid thoracic region
    o Ribs 1 - 7 posterior to anterior accessory motion

  • seated
  • o Palpate for tissue texture changes down medial groove of cervical and thoracic spine
    o Palpate for tissue texture changes on either side of the spinous processes of the cervical and thoracic spine
    o Palpate for any scoliotic deviations

Neurologic Assessment
[edit | edit source]

• A neurological examination should be performed if the patient reports numbness or tingling in the back, shoulder, or more distal upper extremities, or if the patient has focal weakness that would indicate nerve involvement.(1)
Reflexes(2)
o C5 – biceps
o C5 – C6 – brachioradialis
o C7 – triceps
Manual muscle testing
o Elbow
• Flexion (C5,C6)
• Extension (C7)
o Shoulder
• Flexion (C5)
• Extension (C6, C7, C8)
• Abduction (C5)
o Wrist
• Flexion (C6 – 7)
• Extension (C6 – 7)
o Finger
• Flexion (C7 – C8)
• Extension (C7 – C8)
• Abduction (T1)


Sensory examination
o C3 – Occiput
o C4 – Supraclavicular space
o C5 – Anterior shoulder
o C6 – Lateral shoulder
o C7 – Posterior arm
o C8 – Phalanxes 4 – 5
o T1 – Medial arm and axilla


Cranial Nerve Assessment(3)
o Vestibular and Optic cranial nerve screen for cranial nerves 2,3,4,6 and 8
• Snellen Eye Chart to test visual acuity
• Test each eye separately (covering the untested eye); test at a distance of 20 feet. O’Sullivan, Chapter 8, Examination of motor function
• Pupillary reaction, (constriction) is tested by shining a light in the left eye and right eye. If there is an absence of constriction this indicates abnormal function of the optic or oculomotor nerve.
• Extraocular movements are tested by asking the patient to follow a moving finger in a horizontal, vertical and horizontal plane. If they eyeball deviates from it’s normal conjugate position, eye movements are impaired or the patient reports double vision, there is dysfunction of the oculomotor, trochlear and/or abducens nerve(s).
o Trigeminal Nerve
• Sensory: Test noxious and light touch sensations on forehead, cheeks and jaw of the patient. Loss of facial sensations or numbness are reported with a trigeminal nerve lesion
• Motor: Test the muscles of mastication by asking the patient to clench their teeth. Weakness, wasting of muscles or unilateral jaw deviation indicate a trigeminal nerve lesion.
o Facial Nerve
• Facial expression is tested by asking the patient to raise eyebrows, frown, show teeth, smile, close eyes tightly and puff out both cheeks.
• Paralysis is indicated by the patient’s inability to close eye, drooping corner of the mouth or difficulty with speech articulation.
o Unilateral LMN: Bell’s Palsy (Peripheral nerve injury)
o Bilateral LMN: Guillain-Barre
o Unilateral LMN: Stroke
o Glossopharyngeal and Vagus and Hypoglossal nerve
• Listen to voice quality and articulation
• Dysphonia: Hoarseness denotes vocal cord weakness; nasal voice quality indicates palatal weakness.
• Dysarthria: Poor speech articulation.
o Spinal Accessory Nerve
• Have the patient shrug both shoulders upward against resistance. An inability to shrug bilateral shoulders upward against resistance may indicate a lesion to the spinal accessory nerve.

Movement Testing[edit | edit source]

  • AROM, PROM, and Overpressure
  • Passive Intervertebral Motion
  • Muscle Strength

Special Tests[edit | edit source]

References[edit | edit source]


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