Assessment of Chronic Cervical Pain

Introduction[edit | edit source]

Chronic cervical pain is a complex condition demanding a nuanced approach from physiotherapists. This article delves into the intricacies of assessment tools and tests in physiotherapy, focusing on their role in optimizing patient outcomes in chronic cervical pain management.

Patient Outcome Scales[edit | edit source]

1. Visual Analog Scale (VAS):The VAS is a subjective measure where patients rate their pain on a scale, usually ranging from 0 to 10, with 0 being no pain and 10 being the worst imaginable pain. It's a widely accepted tool for assessing pain intensity.[1]

2. Neck Disability Index (NDI):NDI is a self-reported questionnaire assessing the impact of neck pain on daily activities. It consists of ten sections, each addressing different aspects of functional limitations related to neck pain.[2]

3. Patient-Specific Functional Scale (PSFS): PSFS is a patient-specific outcome measure where individuals identify and rate the difficulty of three specific activities affected by their condition. It provides a personalized assessment of functional limitations.[1]

4. Numeric Pain Rating Scale (NPRS):Similar to the VAS, the NPRS is a numerical scale where patients rate their pain intensity. It is a quick and straightforward tool commonly used in clinical settings[1].

5. Cervical Range of Motion (CROM):CROM is an objective measurement tool used to assess the range of motion in the cervical spine. It includes various inclinometers to measure flexion, extension, lateral flexion, and rotation.

Assessment tools in physiotherapy[edit | edit source]

A variety of assessment tools in physiotherapy contribute to a thorough evaluation of chronic cervical pain.

  • Range of Motion (ROM) assessments, such as the Cervical Range of Motion (CROM) device, offer quantitative data on cervical spine mobility
  • Muscle strength assessments, utilizing handheld dynamometers, provide valuable information for treatment planning

These objective measures guide physiotherapists in tailoring interventions to address specific impairments identified during the assessment process.

Functional Test Procedures[edit | edit source]

Functional test procedures play a pivotal role in understanding how chronic cervical pain affects an individual's daily activities. The Functional Movement Screen (FMS) is a widely utilized tool for assessing movement patterns and identifying potential dysfunctional patterns . Physiotherapists emphasize the importance of incorporating functional tests specific to the activities of daily living (ADLs) to enhance treatment relevance . Such detailed assessments enable a targeted approach to rehabilitation, addressing functional deficits identified during testing.

1. Functional Movement Screen (FMS): FMS assesses fundamental movement patterns, helping identify dysfunctional movement that may contribute to chronic cervical pain

2. Upper Limb Neurodynamic Test (ULNT): ULNT assesses the neural mobility of the upper limb, aiding in the diagnosis of nerve-related cervical pain

   3. Dynamic Gait Index (DGI):DGI assesses a patient's ability to perform various walking tasks, providing insights into balance and coordination affected by chronic cervical pain

4. Timed Up and Go (TUG):TUG measures the time taken by a patient to stand up, walk a short distance, and return, evaluating mobility and functional performance

5. Single Leg Stance Test: This test assesses balance and proprioception by having the patient stand on one leg for a specified duration, revealing potential impairments related to cervical pain

6. Nine-Hole Peg Test: This test evaluates fine motor skills and hand dexterity, providing insights into the impact of cervical pain on upper limb function

7. Functional Reach Test: The Functional Reach Test measures the maximal distance a person can reach forward while standing, assessing dynamic balance and stability

8. Four Square Step Test (FSST): FSST assesses dynamic balance and the ability to step over obstacles in a specific sequence, providing insights into mobility affected by cervical pain

9. Jamar Handheld Dynamometry: Handheld dynamometry assesses handgrip strength, providing information on upper limb strength and potential impairments related to cervical pain

10. Lateral Flexion Endurance Test: This test evaluates the endurance of cervical lateral flexor muscles, providing insights into muscular endurance related to cervical pain

Special Tests in Physiotherapy[edit | edit source]

Special tests in physiotherapy are designed to provide specific diagnostic information. For chronic cervical pain, tests like Spurling's Test and the Shoulder Abduction Test help identify potential nerve root compression or radiculopathy . Clinical expertise involves judiciously incorporating these special tests to complement the overall assessment, aiding in accurate diagnosis and treatment planning .

Propioception assessment[edit | edit source]

Assessing proprioceptive deficits in patients with chronic cervical disorders is crucial for designing effective rehabilitation programs.

To evaluate proprioception, clinicians often employ various methods, including

  • joint position sense-Joint position sense tests involve asking the patient to replicate specific joint positions to determine their accuracy and awareness of limb positioning
  • movement reproduction tasks- Movement reproduction tasks assess the ability to reproduce complex movements, providing insights into the patient's motor control and proprioceptive feedback
  • vibration sense assessments. [3]-which involve the use of vibratory stimuli, help evaluate the patient's sensitivity to proprioceptive cues.


In the context of chronic cervical pain, impaired proprioception is frequently observed, leading to compromised postural stability[4]. To address this, rehabilitation programs should incorporate targeted exercises aimed at enhancing proprioceptive awareness and restoring postural control. These exercises may include balance drills on unstable surfaces, proprioceptive neuromuscular facilitation techniques, and specific joint mobilizations to stimulate proprioceptive receptor[5].

Neuromuscular Dysfunction Assessment[edit | edit source]

1. Manual Muscle Testing (MMT):Conduct a systematic evaluation of individual muscle groups surrounding the cervical spine using MMT. Focus on key movements such as cervical flexion, extension, lateral flexion, and rotation. Grade the strength on a standardized scale (e.g., 0 to 5) to quantify and document any deficits accurately[6]

2. Isokinetic Dynamometry: Utilize isokinetic devices to assess muscle strength dynamically and at various speeds. This provides a more comprehensive understanding of muscle performance during functional movements and can help identify any velocity-dependent deficits.[7]

3. Isometric Strength Assessment: Measure isometric muscle strength using a handheld dynamometer. Apply resistance against specific cervical movements, such as isometric flexion, extension, and rotation, to quantify the force generated by individual muscle groups.[8]

4. Endurance Testing: Evaluate the endurance of cervical muscles by assessing the ability to sustain contractions over time. This is particularly relevant for patients with chronic conditions, as endurance deficits may contribute to functional limitations.[9]

5. Surface Electromyography (sEMG): Employ sEMG to analyze muscle activity patterns during various tasks. This involves placing surface electrodes on specific muscles to record electrical activity, providing insights into muscle coordination, recruitment patterns, and potential areas of dysfunction.[10]

6. Functional Movement Assessment: Evaluate the patient's ability to perform functional movements relevant to their daily activities. Assess dynamic tasks such as head turns, tilts, and controlled movements in different planes to identify any compensatory patterns or limitations.[11]

7. Neurodynamic Testing: Include neurodynamic tests to assess the mobility and sensitivity of neural structures associated with cervical pain. This can help identify any neural tension or irritation that may contribute to neuromuscular dysfunction.[12]

8. Postural Assessment: Consider the impact of posture on neuromuscular function. Evaluate static and dynamic postures to identify any abnormalities that may contribute to muscle imbalances and pain[13].

9. Patient-reported Outcomes: Integrate patient-reported outcomes, such as pain scales and functional questionnaires, to gain a holistic understanding of the patient's subjective experience and correlate it with the objective findings from the assessments

[14]

Deep Neck Flexors Dysfunction Assessment[edit | edit source]

Assessing deep neck flexor dysfunction in patients with chronic cervical pain involves a comprehensive evaluation of muscle activity, coordination, and feedforward mechanisms.

1. Surface Electromyography (sEMG): Employ sEMG to directly measure the electrical activity of the deep neck flexor muscles during various tasks. Place surface electrodes over specific muscle groups, such as the longus colli and longus capitis, and assess their activity levels, looking for reduced EMG activity and delayed activation during arm movements[15]

2. Functional Movement Assessment: Integrate functional tasks that involve both the upper extremities and neck flexors. Evaluate the patient's ability to perform arm movements while monitoring deep neck flexor activation. This could include tasks like reaching, lifting, or carrying objects to observe any disruptions in the feedforward mechanism.[15]

3. Neck Flexor Endurance Test: Evaluate the endurance of deep neck flexors by assessing their ability to sustain contractions over time. This can be done by asking the patient to perform sustained neck flexion against gravity or resistance while monitoring for signs of fatigue and compensatory muscle recruitment[16].

4. Real-time Ultrasound Imaging: Utilize real-time ultrasound imaging to visualize the deep neck flexors in action. This allows for a direct observation of muscle activation and can be particularly helpful in assessing the timing of muscle recruitment during specific movements[17]

5. Feedforward Mechanism Testing: Implement tasks that challenge the feedforward mechanism of the deep neck flexors. For example, introduce unpredictable arm movements and observe the patient's ability to anticipate and activate the deep neck flexors in advance.[15]

6. Clinical Observation: Observe the patient's posture and movement patterns during routine activities. Look for signs of compensatory strategies, such as over-reliance on superficial neck muscles or altered head and neck positioning, which may indicate dysfunction in the deep neck flexors[18].

Neck Flexor Muscles Assessment[edit | edit source]

1. Manual Muscle Testing (MMT): Perform manual muscle testing to assess the strength of neck flexor muscles. Use standardized grading scales to evaluate the force exerted during movements such as cervical flexion, assessing the strength of muscles like the longus colli and longus capitis[6]

2. Isometric Strength Assessment: Utilize a handheld dynamometer to measure isometric strength of the neck flexor muscles. Apply resistance against specific movements, such as isometric flexion, to quantitatively assess the force generated by the muscles.[8]

3. Endurance Testing:Evaluate the endurance of neck flexor muscles by assessing their ability to sustain contractions over time. This can be achieved through tasks like maintaining a prolonged neck flexion position or performing repeated flexion movements[9].

4. Real-time Ultrasound Imaging: Use real-time ultrasound imaging to visualize the activation and thickness of the deep neck flexor muscles, providing direct feedback on muscle function during different tasks[15]

5. Surface Electromyography (sEMG): Employ sEMG to measure the electrical activity of neck flexor muscles during dynamic activities. This allows for the assessment of muscle coordination and activation patterns in real-world scenarios[10]

6. Range of Motion Assessment:Evaluate the range of motion of the neck, particularly in flexion. Assess any restrictions or compensatory movements that may indicate issues with the flexibility or strength of neck flexor muscles[13]

7. Functional Movement Assessment: Include functional tasks that involve neck flexion, such as nodding or bringing the chin to the chest, to assess the coordination and quality of movement of the neck flexor muscles[19]

8. Neck Posture Analysis: Perform a thorough analysis of neck posture during static and dynamic activities. Identify any deviations from optimal alignment that may be indicative of muscle imbalances or weaknesses in the neck flexors[16]

9. Patient-reported Outcomes: Integrate patient-reported outcomes, such as pain scales and functional questionnaires, to understand the subjective experience of the patient and correlate it with the objective findings from the physical assessments[14]

Assessment of Mental Health with Chronic Cervical Pain[edit | edit source]

Conclusion[edit | edit source]

In conclusion, a meticulous approach to assessment using patient outcome scales, physiotherapy tools, functional tests, and special tests is paramount for optimizing outcomes in chronic cervical pain management. The integration of these tools, supported by evidence-based practices, empowers physiotherapists to tailor interventions that address each patient's unique needs, ultimately enhancing the overall quality of care.

  1. ↑ 1.0 1.1 1.2 Hawker GA, Mian S, Kendzerska T, French M. (2011). Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP). *Arthritis Care & Research, 63*(S11), S240-S252.
  2. ↑ Vernon H, Mior S. (1991). The Neck Disability Index: a study of reliability and validity. *Journal of Manipulative and Physiological Therapeutics, 14*(7), 409-415.
  3. ↑ Ledin, T., & Fransson, P. A. (2002). Effects of postural disturbances with fatigued trapezius muscles or with 20% local anesthesia of the skin overlying the neck region on the proprioceptive ability at the shoulder joint. Neuroscience Letters, 323(3), 193–196.
  4. ↑ Treleaven, J., Jull, G., & LowChoy, N. (2006). The relationship of cervical joint position error to balance and eye movement disturbances in persistent whiplash. Manual Therapy, 11(2), 99–106.
  5. ↑ Jull, G., & Moore, A. (2007). The role of the craniocervical and cervicothoracic junctions in the management of disorders of the neck and upper thoracic spine - Part 2: Treatment. In: Boyling JD, Jull GA, editors. Grieve's Modern Manual Therapy of the Vertebral Column. Edinburgh: Churchill Livingstone. p. 291-302.
  6. ↑ 6.0 6.1 Hislop, H. J., & Montgomery, J. (2007). Daniels and Worthingham's Muscle Testing: Techniques of Manual Examination (8th ed.). Saunders.
  7. ↑ Perrin, D. H. (1993). Isokinetic Exercise and Assessment. Human Kinetics.
  8. ↑ 8.0 8.1 Bohannon, R. W. (2006). Hand-Held Dynamometry: A Primer. Journal of Hand Therapy, 19(2), 137–153.
  9. ↑ 9.0 9.1 Mathiowetz, V., Weber, K., Volland, G., & Kashman, N. (1984). Reliability and validity of grip and pinch strength evaluations. The Journal of Hand Surgery, 9(2), 222–226.
  10. ↑ 10.0 10.1 Merletti, R., & Parker, P. A. (2004). Electromyography: Physiology, Engineering, and Noninvasive Applications. Wiley-IEEE Press.
  11. ↑ Cook, G., Burton, L., & Hoogenboom, B. J. (2006). Pre-participation screening: the use of fundamental movements as an assessment of function - part 1. North American Journal of Sports Physical Therapy, 1(2), 62–72.
  12. ↑ Shacklock, M. (2005). Clinical Neurodynamics: A New System of Neuromusculoskeletal Treatment. Elsevier.
  13. ↑ 13.0 13.1 Kendall, F. P., McCreary, E. K., & Provance, P. G. (1993). Muscles: Testing and Function with Posture and Pain (5th ed.). Williams & Wilkins.
  14. ↑ 14.0 14.1 Stratford, P., Gill, C., Westaway, M., & Binkley, J. (1995). Assessing Disability and Change on Individual Patients: A Report of a Patient Specific Measure. Physiotherapy Canada, 47(4), 258–263.
  15. ↑ 15.0 15.1 15.2 15.3 Falla, D., Jull, G., & Hodges, P. (2004). Feedforward activity of the cervical flexor muscles during voluntary arm movements is delayed in chronic neck pain. Experimental Brain Research, 157(1), 117–124.
  16. ↑ 16.0 16.1 Jull, G., & Moore, A. (2007). The role of the craniocervical and cervicothoracic junctions in the management of disorders of the neck and upper thoracic spine - Part 3: Cervicothoracic junction. In: Boyling JD, Jull GA, editors. Grieve's Modern Manual Therapy of the Vertebral Column. Edinburgh: Churchill Livingstone. p. 303-319.
  17. ↑ Falla, D., O'Leary, S., Farina, D., & Jull, G. (2007). The change in deep cervical flexor activity after training is associated with the degree of pain reduction in patients with chronic neck pain. The Clinical Journal of Pain, 23(7), 654–660.
  18. ↑ O'Leary, S., Falla, D., Elliott, J. M., Jull, G., & Vicenzino, B. (2009). Muscle dysfunction in cervical spine pain: implications for assessment and management. Journal of Orthopaedic & Sports Physical Therapy, 39(5), 324–333.
  19. ↑ Cook, G., Burton, L., & Hoogenboom, B. J. (2006). Pre-participation screening: the use of fundamental movements as an assessment of function - part 1. North American Journal of Sports Physical Therapy, 1(2), 62–72.
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