Online Continuing Education Courses www.OnlineCE.com www.ChiroCredit.com

ChiroCredit.com™ / OnlineCE.com presents

Physical Diagnosis 151

Chiropractic, Orthopedic, and Neurological Examination of the Neck for the Busy Clinician

Instructor: Marc Lawson, DC, QME

Important Notice: This download is for your personal use only and is protected by applicable copyright laws©. Its use is governed by our Terms of Service on our website (click on ‘Policies’ on our website’s side navigation bar).

Introduction

Health professionals often times will have patients complaining of neck pain, which will lead to a neck examination. In this lesson we will cover the essentials of a basic neck exam. Neck pain (also known as cervicalgia) presents as a common patient complaint. The differential diagnosis for neck pain can be extensive; however, a majority of neck /upper back and upper extremity symptoms stem from neck conditions/pathology. Such biomechanical causes can trigger posterior (axial) neck pain, whiplash-associated disorder (WAD), and pain radiation (radiculopathy). The goal of diagnosis is to identify the cause of pain. Patient history and examination are important in investigating potential causes of neck pain and identifying red flags. Diagnostic imaging should not be routinely ordered because of the high incidence of asymptomatic radiographic abnormalities. If symptoms have not resolved in four to six weeks, re-evaluation and an additional work-up should be considered. Two-thirds of the population report suffering from neck pain at some point in their lives. Approximately 50% of these episodes resolve within one year and 10% of cases become chronic. The purpose of the examination and evaluation by a health care professional is to understand the function or dysfunction of the neck joint. This is accomplished by different methods of analysis and testing which can help determine structural and / or function deficits. Such deficits can show in patient’s complaints, location of symptoms, range of motion (ROM), posture, palpation, muscle strength, nerve function, and other special tests detailed in this course. In orthopedic testing, the doctor wants to reproduce the patient’s pain to reveal possible restriction, weakness, or laxity. The tissues tested are stretched. Use compression and contraction to reveal possible deficits as well as reveal possible “red flags” in the neck area. “Red flags” can include possible fracture, tumor, infection or other severe neurologic

2

compromise usually correlated with medical history which may indicate a need for immediate consultation or referral. In orthopedic and neurologic testing, the doctor looks for neurologic signs and identifies the specific level(s) at which these occur. Orthopedic tests can help identify possible spinal pathology. Neurological deficits are identified by manual muscle strength testing (motor nerve), pinwheel (sensory nerve), and various nerve pathway tests. Additional tests can include myofascial evaluation (such as trigger points), specialized imaging studies (MRI, X-ray, EMG, Blood Lab, etc.) and vascular examination (blood vessel blockage). The human neck is a complex structure that is highly susceptible to irritation. On average 10% of the population will report neck pain in any given month. Possible causes of pain include bones, muscles, ligaments, facet joints, and intervertebral discs. Almost any injury or disease process within the neck or adjacent structures will result in reflexive protective muscle spasm and loss of motion. The aging process of the spine can cause a gradual collapse of the intervertebral discs and degeneration of the facet joints which in some people can lead to nerve or spinal cord impingement. Neck mobility is so important to normal human function and activities that any issues in its normal function are quickly noticed.

Differential Diagnosis Neck pain can have an extensive diagnosis. Most common causes are biomechanical in nature: axial neck pain, whiplash-associated disorder (WAD), and cervical radiculopathy. Less common causes include cervical myelopathy (spinal cord compression), infection, neoplasms, ankylosing spondylitis, spondyloarthropathies, and diffuse idiopathic skeletal hyperostosis, torticollis, cervical dystonia, and major trauma, including fractures, dislocations, and cord injuries. Pain may be part of fibromyalgia syndrome, or may be referred to the neck from other sources, such as shoulder disorders, thoracic outlet syndrome, esophagitis, angina, and vascular dissection. The presence of a positive history of herpes zoster virus (HZV) reactivation should be considered as a long-term complication of a cervical root inflammation, especially in patients in which X-ray and MRI of the cervical spine did not show pathological findings. General Practitioners (GP’s) refer about 30% of new cases for imaging and prescribe a range of drugs. Approximately 22% of which are outside clinical guidelines. These findings suggest a need for further education of GP's, including indications for imaging after whiplash injury, identification of those more likely to develop chronic WAD, and medication management guidelines. WAD carries a large personal and economic burden, so the impact of improvements in GP management is potentially significant.

Basic Anatomy

Cervical spine anatomy is comprised of a structure of bones, nerves, muscles, ligaments and tendons. This type of anatomy provides support, structure and stabilization to the neck while allowing for maximum protection of the spinal cord along with maximum flexibility (otherwise known as range of motion) of the neck region in all directions.

3

The cervical spine begins at the base of the skull and extends through a series of seven vertebral segments that connects to the upper spine. The cervical spine is formed by seven vertebrae – known as C1, C2, C3, C4, C5, C6, and C7. The first cervical vertebra (atlas) is different in structure compared to the rest of the cervical vertebra. It is shaped as a ring that rotates around the second vertebral body (axis). This allows maximum rotation (side to side motion) in the neck between the first two segments of the cervical spine. Unlike the first two cervical vertebrae, the remaining five cervical vertebrae, C3 through C7, are more similar to the rest of the spine, with three joints making up each vertebral segment (a disc in the front and two facet joints in the back). The cervical vertebrae closest to the skull are the smallest, progressively appearing larger as one travels down the length of the cervical spine to the upper back. All of the cervical vertebrae are smaller than the vertebrae in both the thoracic and lumbar spinal area. The cervical vertebrae are each separated by the cervical disk that helps support the head, provides strength, cushion, and overall protection for the cervical spine against sudden impact forces. Range of Motion of the neck region consists of cervical motion in different planes. Motion consists of flexion (forward head motion), extension (backward head motion), lateral flexion (bending neck to touch ear to shoulder) and rotation (turning neck to look over shoulder). Most flexion and extension motions in the neck are controlled by the C5-C6 and C6-C7 segments of the spine which often times in “whiplash” (WAD) cases tend to be the area of injury.

Cervical Spinal Nerves With the exception of C1, all nerves have a ventral and dorsal nerve root that exits through the intervertebral foramen. C1 exits between the cranial occipital bone and 1st cervical vertebra, and frequently does not have a dorsal root. C2 exits between C1 & C2, C3 between C2 & C3 and so forth. C8 exits between the 7th cervical vertebra and the 1st thoracic vertebra. The first thoracic nerve exits between T1 & T2. Therefore, in the cervical region the nerves exit above the referenced segment with the exception of C8, where there is not a corresponding vertebra. All spinal nerves consist of mixed fibers, both sensory and motor. This allows for neuro-transmission from the sensory receptors to the spinal cord, also known as afferent transmission. The ventral nerve root mostly controls efferent transmission. The efferent transmission travels from the spinal cord to the muscles for motor response as well as for the conducting of the sympathetic and parasympathetic pathways. The dorsal root is responsible for the conducting of sensory transmission. The sympathetic chain exits through the ventral root and are involved in elevated heart rate, increased electrical activity of the brain, deep and rapid breathing, and dilation of blood vessels and eyes. The spinal roots form rami, where they traverse through the intervertebral foramen of their respective segment. The rami can either divide or return back towards the spine to provide nerve supply to the meninges, vertebra, and ligaments or move into the periphery to supply the skin, muscles, and viscera, for the “fight or flight” mechanism.

4

The parasympathetic or craniosacral division is comprised of preganglionic neurons located in the brain stem and the sacral region. Its postganglionic neurons are located in close approximation to the organ to be supplied. While the parasympathetic division is considered to be a supportive system for the sympathetic, frequently they have an antagonistic relationship. This antagonistic relationship is balanced and regulated. The parasympathetic division is active during rest for activities such as digestion and the conservation of energy. Hilton’s Law notes: “a nerve trunk which supplies the muscles of any given joint also supplies the muscles which move the joint and the skin over the insertions of such muscles.” Hilton’s Law and supporting electromyography studies suggest that underlying dermatomes contain myotomes and sclerotomes with resulting sensory and motor dysfunction. Should there be an organic or biomechanical encroachment or compression affecting the ventral nerve root, it could result in an autonomic impairment and subsequent viscerotomes. A viscerotome is an area of the viscera supplied with sensory fibers from a single spinal nerve. For example, herpes zoster can produce a dermatome pattern from its lesions. Such dermatomal patterns have defined pain, hyperesthesia, and pustules. These patterns can occur at any level of the spine. Following the active state of the lesions, post-herpetic neuralgia may be experienced for years and is usually triggered by stress and a compromised auto-immune system. Radiculopathies can also follow these pathways with resulting dysesthesia. The spinal nerves have multiple overlapping supply as a protective mechanism against injury as it pertains to nerve innervations of a given structure or organ. Segmental supply (as referenced below) is defined by a variety of different sources, so please be aware that innervations can occur within a segment or two above or below specific reference depending upon the individual defining it.

The bulleted lists below contain information about spinal nerve segment, plexus, innervations of muscle and viscera, and dermatome pattern for each spinal region.

C1 through C8 - The Cervical Region • C1 to C4 forms the Cervical Plexus

• C1 Dermatome pattern: Back of head covering occipital region

• C2 Dermatome pattern: Posterior to the supraoccipital region; laterally from the superior aspect of the ear inferiorly to the posterior aspect of the ear

• C3 Dermatome pattern: Lateral and anterior aspect of the neck

• C4 Dermatome pattern: Superior posterior aspect of neck as well as anterior inferior aspect of neck

• C5 Dermatome pattern: Posterior from superior aspect of the cervical thoracic (CT) junction to anterior superior to or directly on top of the clavicle; from the superior aspect of the CT junction superiorly and slightly posterior across the shoulder down the anterior medial aspect of the arm and forearm to the superior wrist

5

• C6 Dermatome pattern: Inferior aspect of C6 to the posterior upper back & shoulder, and down the lateral aspect of the arm, forearm, to thumb

• C7 Dermatome pattern: Inferior from the CT junction to superior aspect of the upper back to the posterior aspect of the shoulder & distally down the posterior aspect of the arm, forearm, middle & index fingers

• C8 Dermatome pattern: With a broad horizontal distribution it traverses inferior from the CT junction across the superior aspect of the upper back to the posterior aspect of the scapula, beneath the inferior angle and continues superior and laterally to the axilla at which time it traverses from the axilla distally down the medial aspect of the arm, forearm & into the ring and little finger

Signs of Neck Disorder When the patient first presents with signs and / or symptoms of neck joint disorder, such as neck pain, loss of motion, muscle weakness, abnormal sensation, and / or abnormal posture (such as “torticollis”), a neck examination is in order. Before the examination is started a thorough medical history must be taken. A medical history needs to include the following subjects:

• Past illnesses / conditions • Hospitalizations • Medications • Previous fractures • Allergies • History of past injuries • Current supplements taken • Tobacco / alcohol use • Current health conditions

For current health issues the clinician needs to note the following: location, quality, severity level, timing, setting, alleviating/aggravating factors, and any associated symptoms. Note that major childhood illnesses or past injuries in youth can have a major effect on the patient in later life and need to be addressed. Any neurologic issues such as weakness, paralysis, numbness, abnormal sensation, tingling, or tremors need to be covered as well. When the medical history taking is complete, the physical examination can begin. Be aware of med-legal cases. The patient’s past medical history should include a detailed review of the previous medical intervention for any personal and/or workers’ compensation injuries. Based on the medical history and the patient’s current complaints and concerns, the physical examination will include the following:

• General observation of the patient • Routine vitals evaluation (Blood pressure, pulse, etc.) • “Red Flags” screening • A regional neck exam

6

• Neurologic and Orthopedic screening • Chiropractic evaluation

Observation Movement issues or altered posture may indicate the need for specific neurologic and/or orthopedic testing. Severe guarding of cervical motion in all planes, elevated body temperature, elevated blood pressure or elevated pulse rate may indicate possible infection, tumor, or fracture in the spinal area. The physical examination is mostly subjective due to patient response. The parts of the exam that are more objective are taking vitals, reflex testing, and circumferential measurements for atrophy. Physical examination tests that use different range of motion, muscle strength, and pain replication will help pinpoint the cause of neck dysfunction. Beyond location, consider sudden versus insidious onset, various motions and positions that reproduce pain, predisposing physical activities, and effect of walking or weight bearing. Clinical note: Numerous disorders are capable of causing neck pain, and neck pathology can be involved in referred pain syndromes from or to other problem areas (such as stemming from the upper back area or a possible organ issue).

History and Physical Examination

A careful history can yield a diagnosis, or at least categorization of symptoms, in the majority of patients. History should focus on the mechanism of injury (if any) and on symptoms. Any prior neck trauma or symptoms should be noted. Clinicians should be alert for a number of “Red Flags” for potentially serious conditions requiring prompt diagnosis and management. There are many potential sources and causes of neck pain. Diagnosis of specific cause of pain or problem can be difficult at times. This is because symptoms can arise from different spinal levels appearing very similar and thereby difficult to differentiate.

Clinical Highlights Morning stiffness that improves over the course of the day is sometimes indicative of rheumatic causes. Fever, weight loss, night sweats, and other systemic symptoms are indicative of infection or neoplasm. Unremitting night pain, especially in the context of a prior history of malignancy, may be secondary to a bony tumor. Gait disturbance, balance problems, sphincter dysfunction, or loss of coordination suggests myelopathy. Patients should be carefully questioned about past treatment successes and failures. Clinical Note: Many times patients, upon careful history review, can report one sided or repetitive physical activities which can help lead to proper diagnosis of their neck condition. Patients are usually unaware of such one sided activities that over time can lead to neck issues; this is often missed by doctors.

7

Initial Assessment of Neck Area 1. Rule out potential dangerous underlying conditions known as “Red Flags” on the patient. 2. If such “Red Flags” findings are identified then immediate consultation, referral and/or

use of special studies are considered. 3. If “Red Flags” findings are ruled out, then continue with a neck evaluation to formulate a

working diagnosis and treatment plan. 4. Isolate the problem area. 5. Determine patient’s presenting issues through examination, testing and history to form a

working diagnosis. 6. Determine if referral or additional testing is indicated.

Patient examination findings and responses along with their medical history can help identify "Red Flags" which can be caused by serious underlying spinal condition. Such spinal conditions can include the following: tumor, infection, spinal fracture, or major neurologic compromise. Their absence can help rule out the need for referral or use of special studies during the initial evaluation. The patient’s medical history and physical examination can also help rule out non-spinal pathology such as organ or space-occupying lesions which can mimic neck symptoms. Routine vital exams such as blood pressure, pulse, medical history, and current height and weight can also alert the clinician to possible “Red Flags” suggestive of referral or additional testing. The doctor needs to review the following structures when diagnosing the possible causes of neck pain: vascular, nerve, airway, digestive, muscle, bone, or referral from other areas of the body.

“Red Flag” causes of neck pain can include the following:

• Carotid artery dissection • Possible referred pain from acute coronary syndrome (“Heart Attack”) • Head and/or neck cancer • Possible infections such as retropharyngeal abscess, epiglottitis, etc.

Physical Examination A careful physical examination is vital for differentiating potential causes. Inspection should focus on posture, ease of movement, and visible deformities. Palpation of soft tissue and bony and other cervical structures such as thyroid, lymph nodes, and salivary glands should be performed. Cervical range of motion in flexion, extension, bilateral lateral bending, and bilateral rotation should be noted, along with bilateral shoulder range of motion. Neurologic examination of sensory and motor function as well as reflexes is vital. Several special maneuvers can be helpful. Axial loading of the neck while the head is extended and rotated (Spurling maneuver) will often provoke radicular pain. Placing the affected hand on top of the head (abduction relief sign) takes stretch off of the affected nerve root and may decrease or relieve radicular symptoms. An electric shock sensation down the center of the back after neck flexion (Lhermitte sign) is indicative of cervical spinal cord pathology such as cervical myelopathy. One potential source of neck pain derives from skeletal muscle of the neck area. Causes of neck pain in muscle tissue include muscle strains (“pulled muscles”), muscle spasm, and muscle

8

imbalances, which can lead to antalgic lean of the neck, known as torticollis. In particular, facet joints in the cervical spine are most commonly injured during movements involving a rotational or twisting component. When injured, pain is often sharp and localized to the area of the affected facet joint. Often times this can be misdiagnosed as a herniated disk, torn muscle, fracture or deep infection. Serious issues located deep in the anterior neck and true arthritic facet degeneration may also imitate cervical facet disorders and need to be ruled out. Pain patterns of cervical facet disorders will typically show as:

• Episodes of cervical facet joint pain which are usually intermittent, unpredictable, and can occur a few times per month or year

• Persisting point tenderness overlying the inflamed facet joints and some degree of loss in the spinal muscle flexibility (known as guarding)

• More discomfort with extension then flexion movement • Cervical facet joint problems that can be painful locally or radiate pain into the shoulders

or upper back (rarely does pain radiate in the front or down arm or fingers as a herniated disc might)

Because recurrent painful episodes can be frequent and unpredictable in timing and extent, patients feel that “it’s all in your head”; more psychological than biomechanical in nature. Clinical Note: Imaging studies can often miss such muscle damage and a true understanding of neurophysiology of muscle spasm and muscle imbalances is not well solidified. Positive findings from imaging studies should correlate with the physical exam. Other sources and causes of neck pain can occur from the following: muscle spasms, spinal disc herniation of the neck, degenerative disc disease, spondylolisthesis, osteoarthritis (degenerative joint disease), spinal stenosis, trauma, cancer, infection, fractures, major neurological compromise, inflammatory disease, obesity, poor head / neck posture, chronic trauma, genetic factors including genetic diseases, altered biomechanics, micro trauma, and loss of normal cervical curve. Over time, if spinal problems have lingered without appropriate rehabilitation, arthritis will likely be present. If severe enough, as is commonly the case, bony arthritic enlargement of the joint can impinge upon spinal nerve roots and produce symptoms such as pain, numbness, and tingling down the arm as well as arm / hand weakness, in addition to neck pain. Spondylolisthesis. is anterior displacement of a vertebra or the vertebral column in relation to the vertebrae below. Spondylolysis is defect or stress fracture in the pars interarticularis of the vertebral arch. Anterolisthesis is vertebra above slips anterior onto the vertebra below, Retrolisthesis is vertebra above slips posterior onto the vertebra below. Clinical Note: Often times old injuries and childhood disease will become evident. I find it helpful to point out such issues to the patient. They will often respond that they forgot to mention it in the history section which can have a major effect on your working diagnosis.

9

Neck Exam

Position For the purpose of examination, the patient usually starts in a standing posture for testing, followed by various other positions such as sitting, supine, and prone on a flat exam table. Access to skin viewing and contact can be done by either gowning the patient or asking male patients for shirt removal. Inspection Observe for scars, swelling, lesions, surgery, trauma signs, skin discoloration, trophic changes, and muscle atrophy. Check cervical curve, forward head tilt, scoliosis, posture, both shoulder levels, and arm lengths. Observe Look for antalgic position when moving or sitting such as a lean to one side. Look for guarded motion which may indicate muscle spasm. The doctor may choose to rate such issues as mild, moderate, or severe difficulty. Pain upon motion can be noted as well. If the patient is using a cane, walker, wheelchair or other assisted device this should be noted. Clinical Note: Often times when examining a patient, a doctor will observe the patient getting off and on the exam table and even observe them leaving the office. This will give a better assessment of their true ability to move around as compared with their stated ability. Often times in med-legal exams by a third party doctor any such differences can negatively affect the course of the case for the patient.

Types of Neck Pain

There are many causes of neck pain. Most neck pain can be linked to biomechanical causes such as axial (posterior) neck pain, whiplash-associated disorder (WAD), cervical radiculopathy and myelopathy. Other less common causes include cervical myelopathy (spinal cord compression), infection, neoplasms, rheumatic causes, torticollis, cervical dystonia, and major trauma. Major trauma includes fractures, dislocations, disc, and cord injuries. Pain also may be referred to the neck from other sources such as shoulder disorders, thoracic outlet syndrome, esophagitis, angina, and vascular dissection. Even less common causes can include head injury, rheumatoid arthritis, Carotidynia, congenital cervical rib, mononucleosis, rubella, certain cancers, ankylosing spondylitis, esophageal trauma, subarachnoid hemorrhage, lymphadenitis, thyroid and tracheal trauma. Neck pain may also present as part of complex generalized pain syndromes such as fibromyalgia. Posterior or axial neck pain begins with sprain or strain in the muscles and /or soft tissues of the neck. This can be a result of trauma and/or poor posture over time. Other factors involving the muscular and ligamentous areas of the neck can include sleep habits, ergonomics (such as computer monitor, eyeglass bifocal position, etc.), stress, chronic muscle fatigue, postural changes due to other primary pain sources (shoulder, TMJ joint, cranial tension), or degenerative changes of the cervical discs or facet joints. Overuse of neck muscles can lead to an injured ligament or disc in the neck which in turn leads to pain. If untreated, over time discs begin to diminish and shrink in size due to aging, resulting in altered bio mechanics allowing the vertebrae and facet joints to come in contact against each another.

10

Whiplash-associated disorder (WAD) is acute or subacute neck pain resulting from an acceleration/deceleration type of injury, with transfers of energy to the neck. Multiple pain causes are usually involved, including myofascial, ligamentous, discogenic, and facet joint sources. The most common cause is rear-end motor vehicle crashes, but WAD can also occur from events such as falling or diving injuries. Cervical radiculopathy is motor and/or sensory changes in the neck and arms resulting from pressure on a cervical nerve root, usually by osteophytes or disk material. Most cases are associated with foraminal encroachment by degenerative bony changes. Some cases involve herniated disk material. Myelopathy is the manifestation of long tract signs resulting from a decrease in the space available in the cervical canal for the spinal cord. A number of factors contribute to extrinsic pressure, including the congenital cord diameter, osteophytes, protruding disk material, dynamic changes in canal diameter and the cord itself, and the vascular supply to the cord. Recent vertebral fracture of the cervical area causing neck pain can be present usually as a result of a recent trauma such as auto accident, work injury, or even a slip and fall. Due to osteoporosis in older patients the vertebral body can become brittle and more subject to fracture from such injuries. Other conditions such as old compression fractures, boney arthritis of the spine, joint instability of the vertebral bodies, curvature of the spine, and decreased disc space can cause back pain as well. Imaging studies such as X-ray, CAT scan or an MRI can help rule out such conditions. Clinical Note: Patients will comment they have been treated by other doctors for neck issues without help, so I always check out other possible pain sources areas as noted above.

Cardiovascular Check for temperature, tenderness, swelling, and carotid pulse in the neck area. Note any abnormalities or possible “Red Flags”.

Movement Tests Check for ranges of motion (ROM) of the neck joint through active testing. Generally accepted values for cervical range of motion are: Flexion 40-45° Extension 45-70° Rotation 50-60° Lateral Flexion 20-45° Note any limitations in ROM as well as pain presenting. Clinical Note: Always compare both sides with active and passive ranges of motion of the neck joint as well as any deformity present. Be aware of age, physical conditioning (or lack of) and health histories of the patient as these tests are performed. An older person that sits all day at a desk job usually will have more restriction of motion in the neck joint as compared to a dance instructor. A younger person would be expected to have greater range of motion than a geriatric patient in general.

11

Differential diagnosis of neck pain can be caused by various issues from both the neck and upper back. The head is supported by spinal curves in these areas which is often the origin of such symptoms. The lower neck and upper back area help support the head. The upper cervical area (C1 to C3) allows for the greatest range of motion in the neck area. Disease process, poor posture and/or trauma can lead to muscle imbalances causing pain. Nerve irritation (“pinched nerves”) and different types of joint disruption can also cause such pain symptoms. Other factors such as chemical, physical and/or emotional issues can also lead to neck pain. Neck pain can also be part of referral pain from the upper back, head, and TMJ area.

Cervical Tests

Neck Flexors Strength Test This test checks the strength of the neck flexors. Have patient prone then lift head up and resist doctor’s downward pressure. Positive sign: Weakness of anterior neck flexors if patient is unable to flex the neck against gravity or against pressure. Anterolateral Neck Flexors Strength Test This test checks the strength of the anterolateral neck flexors. Have patient prone, rotate to one side (grade 3) and resist doctor’s downward pressure. Positive sign: Weakness of anterolateral flexors if patient is unable to rotate the neck against gravity or against pressure. Cervical Compression Test This test checks compression of cervical nerve root or facet joint irritation in the cervical spine. Have patient sitting; the doctor slowly pushes down on top of patient’s head. Positive sign: Radiating pain or other neurological signs in the arm (indicates nerve root) and/or pain local to the neck or shoulder (indicates facet joint irritation). Cervical Distraction Test This test checks compression of cervical nerve root or facet joint irritation in the cervical spine. Have patient sitting, the doctor slowly tractions up on the patient’s head. Positive sign: Relief of radiating pain, neurological signs into arm, neck or shoulder. First Rib Mobility Test This test checks the mobility of the first rib. Patient is seated, fully rotates their head away from the side being tested, and then fully flexes the head to their chest. Positive sign: Patient has limited neck flexion, tight scalenes, narrowing IVF, cervical facet syndrome or spastic prevertebral muscles. Adson's Test (Scalene Maneuver) This test decreases the inter-scalene space (between anterior and middle scalene muscles) and increases any existing compression of the subclavian artery and lower components (C8/T1) of

12

the brachial plexus against the first rib. With the patient sitting or standing, the doctor palpates the radial pulse and has the patient bend the head backward toward the side being examined, to take a deep breath, and to tighten the neck and chest muscles on the side tested. Positive sign: Weakening of the pulse or increased paresthesia indicate positive sign of pressure on the neurovascular bundle, effecting subclavian artery from pressure of the scaleni musculature, thus indicating a probable cervical rib or scalenus anticus syndrome. Kernig's Neck Test This test checks for possible spinal cord issues. The supine patient places both hands behind his head and forcibly flexes his head toward his chest. Positive sign: Pain in either the neck, lower back, or down the lower extremities indicates meningeal irritation, nerve root involvement, or irritation of the dural coverings of the nerve root. Soto-Hall Test This test is primarily employed when fracture of a vertebra is suspected. The patient is placed supine flat. One hand of the doctor is placed on the sternum of the patient, and mild pressure is exerted to prevent flexion at either the lumbar or thoracic regions of the spine. The other hand of the examiner is placed under the patient's head, and the head is slowly flexed toward the chest. Flexion of the head and neck on the chest progressively produces a pull on the posterior spinous ligaments from above, and when the spinous process of the injured vertebra is reached, an acute local pain is experienced by the patient. Positive sign: Pain upon flexion, possible cervical fracture present. Cervical Percussion Test This test is for integrity of spinal motor unit, disk and nerve root. The neck of a sitting patient is flexed to about 45º while the doctor percusses each of the cervical spinous processes and adjacent superficial soft tissues with a rubber-tipped reflex hammer. Positive sign: Point tenderness on testing suggests a fractured or acutely subluxated vertebral motion unit or a localized sprain or strain, while symptoms of radicular pain suggest radiculitis or an IVD lesion. Eyelid Strength Test This test confirms Bell’s palsy. Patient is seated. Patient keeps their eyes closed, doctor attempts to slowly open the patient’s eye on the affected side with clean hands. Positive sign: Patient cannot keep affected eye closed; indicates Bell’s palsy. Posterolateral Neck Flexors Strength Test This test checks the strength of the posterolateral neck flexors. Patient extends the neck then rotates the head towards the side being tested and lifts against gravity. Doctor holds head area of the unaffected side, and then pushes in an oblique posterolateral direction, away from the tested side. Patient is supine, abducts arm to 90°, flexes the elbows to 90°, and rests dorsal hands on the table. Positive sign: Weakness of the posterolateral neck flexors if the patient is unable to hold the neck against gravity or doctor’s pressure.

13

Sinus Illumination Test This test checks for possible infection of the frontal and maxillary sinuses. The test is performed in a dark room; using a bright small flashlight covered with clear plastic bag the doctor places the flashlight inside the patient mouth, against the roof of the mouth to view the maxillary sinus. The frontal sinus is checked by placing the flashlight against the medial aspect of the eyebrows. Positive sign: Possible infection or blocked sinus do not glow red (as would a normal sinus) when illuminated. Spurling’s Test This test is for possible compression of a nerve root or facet joint irritation in the lower cervical spine. This is similar to the cervical compression test, but patient’s neck is lateral. Patient flexes and rotates the head to the affected side as doctor slowly applies compression downward on the head of patient. Positive sign: Radiating pain or other neurological signs in the same side arm (nerve root) and/or pain local to the neck or shoulder (facet joint irritation). Note that placing the affected hand on top of the head (known as abduction relief sign) takes stretch off of the affected nerve root and may decrease or relieve radicular symptoms. Lhermitte's Sign (Barber Chair Phenomenon) Patient notes electric shock sensation down the center of the back after neck flexion or doctor percussion of cervical spine which is indicative of cervical spinal cord pathology such as cervical myelopathy. Swallowing Test Test checks for trigger points on the Sternocleidomastoid (SCM). Patient swallows as doctor pinches most tender point on the SCM. Positive sign: Pain reduces when the patient swallows as you pinch the tenderest point. If no change, pain may be caused by possible throat infection, hematoma and bony growth of the cervical spine, or tumor. These causes need to be ruled out. TMJ (Jaw) Test This tests restriction of the TMJ joint. Patient to open jaw and insert as many of their own flexed proximal interphalangeal joints of the non-dominant hand as possible. Positive sign: Patient can only get one or two knuckles between their teeth. Upper Trapezius Strength Test This tests the strength of the Upper Trapezius Muscle. Patient is sitting raising both shoulders. Doctor pushes down checking for weakness. Positive sign: Weakness of the Upper Trapezius if the patient is unable to hold their shoulders up against doctor pressure.

14

Vertebral Artery Test This test checks for possible ischemia or deficiency of the vertebral artery. Patient is seated and actively rotates the head fully to one side and then extends the neck for 30 seconds. Repeat on other side. Positive sign: Patient complains of dizziness, nystagmus, or both, suggestive of “Red Flags.” Any further testing or treatment is contraindicated and referral of patient to the proper specialist is advised. Valsalva's Test This test can rule out space occupying lesion. Have the patient hold breath and bear down. Positive sign: Reproduce spinal or limb pain which suggests space occupying lesion. Overview Summary: Muscle tests: Neck Flexors Strength Test, Anterolateral Neck Flexors Strength Test, Posterolateral Neck Flexors Strength Test, Adson's Test, Swallowing Test, TMJ (Jaw) Test, Upper Trapezius Strength Test. Nerve root irritation / Facet tests: Cervical Compression Test, Cervical Distraction Test. First Rib Mobility Test, Cervical Percussion Test, Spurling’s Test. Spinal Cord Tests: Kernig's Neck Test, Soto-Hall Test, Lhermitte's Sign. Disc Test: Cervical Percussion Test, Valsalva's Test.

Neurological Exam of the Neck

Examine the patient to rule out possible upper motor neuron lesions. Signs include: General muscle weakness, spasticity, hyperreflexia, primitive reflex signs (grasp, suck and snout reflexes), and Babinski sign. Lower motor neuron lesions are characterized by general weakness, hyporeflexia, muscle hypotonia, atrophy and fasciculations (fine movements of the muscle under the skin). Note the position of the body that the patient assumes when moving, walking, and sitting on the examination table. Examine the patient for tics, tremors and fasciculations. Note their location and quality. Also note if they are related to any specific body position or emotional state. Note any paralysis or weakness when a patient assumes an abnormal body position. Usually a central lesion shows greater weakness in the extensors than in the flexors of the upper extremities, but opposite in the lower extremities - greater weakness in the flexors than in the extensors. Clinical Note: While rare in a Chiropractic practice to find such neurological lesions, it is important to be aware especially in patients with progressive neurological disease processes. Of concern in children are Occipitocervical distraction injuries (OCDI) which would indicate possible neurologic referral. While clear cases of frank atlanto-occipital dislocation (AOD) are treated with surgical stabilization, the approach for less severe cases of OCDI is not standardized. Significant findings are found in the clinical and radiographic

15

findings including: (1) the mechanism of injury, (2) the patient's age, (3) CT/CT angiography of head and neck findings and parameters, (4) MRI findings, and (5) neurological exam, for the purpose of determining the possibility and severity of the OCDI instability. OCDI is a potentially devastating injury, especially in children. Missing the diagnosis can have potentially catastrophic consequences, reverting to surgical fixation, while in less severe cases can subject children to unnecessary operative risk and permanently reduce their range of motion. As you examine the major muscle groups of the neck and arm note the following:

• Overall appearance of the muscle (wasted, highly developed, or normal) • Tone quality of the muscle (flaccid, clonic, or normal) • Strength of each muscle group in the neck and arm

In major cervical injuries the following spinal levels are affected:

• C-1/C-2 spinal levels will often result in loss of breathing, requiring use of mechanical ventilators or diagram breathing

• C3 vertebrae and above spinal levels: Typically results in loss of diaphragm function, necessitating the use of a ventilator for breathing

• C4 spinal level: Loss of function at the biceps and shoulders • C5 spinal level: Loss of function at the shoulders, biceps, wrists and hands • C6 spinal level: Some loss of wrist control and complete loss of hand function • C7 and T1 spinal levels: Loss of dexterity in the hands and fingers, limited use of arms

Manual Muscle Testing of Neck Muscles

Use the following scale to evaluate major muscle group’s strength: 0 - No muscle contraction is detected. 1 - A trace contraction is noted in the muscle by palpating the muscle while the patient attempts to contract it. 2 - The patient is able to actively move the muscle when gravity is removed. 3 - The patient may move the muscle against gravity, but not against resistance from the examiner. 4 - The patient may move the muscle group against some resistance from the examiner. 5 - The patient moves the muscle group and overcomes the resistance of the examiner - considered normal muscle strength.

Note – Always repeat each muscle test three times on each side. Always compare both sides for muscle weakness and symmetry.

Major Muscle Tests of the Neck In general, the following muscle groups of the neck can be tested for strength: Patient Cervical Flexion against resistance:

• MUSCLES: Longus capitus/colli, rectus capitis anterior, anterior scalene, SCM

16

Patient Cervical Extension against resistance:

• MUSCLES- Splenius capitus/cervicis, Eractor Spinae, Obliquus capitis superior, rectus capitis posterior major and minor, semispinalis cap/cerv, upper trapezius

Patient Cervical Anterolateral Flexion against resistance:

• MUSCLES: Sternocleidomastoid Clinical Note: Most patients tend to test at the 4 and 5 number range on this scale. In my experience you will find a correlation between major muscle group muscle weakness and associated motor nerve involvement. This in turn will often correlate with the patient’s current complaints. Muscle girth measured at mid arm and mid forearm when compared bilaterally can indicate possible muscle atrophy or wasting disease, also suggestive of nerve impingement.

Sensory Dermatomes of the Upper Back / Neck A dermatome is defined as a patch of skin that is innervated by a given spinal cord level. After an injury, the dermatomes can expand or contract, depending on the plasticity of the spinal cord. To test for nerve root damage, the corresponding dermatomes supplied by that nerve root may be tested for abnormal sensation. To test a dermatome, you can use a pinwheel, cotton ball, paper clip, or even a pin. The patient should be asked to provide feedback regarding their response according to the stimuli. Scale of responses to abnormal sensation:

• Hyperesthesia - excessive sensation • Hypoesthesia - decreased sensation • Anesthesia - loss of sensation • Parasthesia - numbness, tingling, burning sensation

The doctor can access which dermatomes have abnormal sensation: Area: Spinal cord level: Shoulders C4, C5 Inner and outer forearms C6 and T1

Hands to fingers C6, C7, C8 Upper extremities reflexes can also be checked for normal response for the following spinal nerves: Area: Spinal cord level:

Biceps C5-C6

Distal Radius C6-C7

Triceps C7 Reflex testing will trigger an involuntary muscular response when tapped by the rubber hammer on the associated tendon. When reflex responses are hyper responsive, sluggish or absent, this

17

could be due to spinal cord, nerve root, peripheral nerve, or possible muscle damage. Disruption of the sensory and/or motor nerves will elicit an abnormal response upon testing. A scale from 0 to +4 is used for reflex testing. Scale is noted as: 0 = absent, +1 = sluggish, +2 normal, +3 = hyperactive reflex without clonus, +4= hyperactive reflex with clonus. Clonus is a series of involuntary, rhythmic, muscular contractions and relaxations, which can be caused by some neurological conditions, particularly associated with upper motor neuron lesions, sometimes accompanied by spasticity (abnormal contracted muscle tone). Clonus causes large motions that are usually started by reflex testing. Small, spontaneous twitches known as fasciculations are usually caused by lower motor neuron pathology which is different than clonus. Upper extremities reflexes are checked for normal response for the following spinal nerves: Area: Spinal cord level:

Biceps C5-C6

Distal Radius C6-C7

Triceps C7 Spinal Cord Injuries Direct injury to the spinal cord can be most devastating to the patient, who will often need increased management and referral among different health professionals. Evaluation, documentation, and report writing must elicit communication clearly among all parties involved. In report writing, please note the difference between neurological and rehabilitation definitions of spinal cord injury levels. Given the same neurological examination and findings, different health professionals may assign different spinal cord injury levels. In general, neurologists define the level of injury as the first spinal segmental level that shows abnormal neurological loss. In contrast, other health professionals will define level of injury as the lowest spinal segmental level that is normal. Most orthopedic surgeons tend to use the bony level of injury as the level of injury. Clinical Note: In your exam notes and report writing it is best to write out the lowest level of normal findings, followed by injury level and then abnormal findings to avoid confusion.

Chiropractic Evaluation

Chiropractic evaluation consists of static and motion palpation of the cervical joints to determine fixations and restrictions of the spinal column. Chiropractic nerve tracing following the path of the spinal nerve's dermatomal pattern can also help identify possible spinal subluxations. Patient’s posture analysis standing, sitting, and laying down can help detect gross imbalances of the neck and upper back/shoulder area due to pain, muscle weakness and posture. Trigger Points Often use by chiropractors, trigger points (trigger sites) are described as hyperirritable spots in skeletal muscle that have palpable nodules in taut bands (“knots”) of muscle fibers. This usually is a common source of pain to the patient. Direct compression of a trigger point can elicit local tenderness, referred pain, or local twitch response (no muscle contraction).

18

The following characteristics are found in trigger points: • Pain is tied to an irritable focal point in skeletal muscle or fascia, not caused by trauma,

inflammation, degeneration, neoplasm or infection. • This painful point is felt as a band in the muscle, and a local twitch response is observed

upon stimulation of the trigger point. • Palpation of the trigger point reproduces the patient's complaint of pain, and the pain

radiates in a distribution typical of the specific muscle harboring the trigger point. • Findings on neurological examination cannot explain the patient’s pain complaints.

Myofascial Pain Syndrome Myofascial (muscle and fascia) pain syndrome is a focal hyperirritability in muscle that can strongly modulate central nervous system functions. Fibromyalgia is widespread pain and deep tissue tenderness including muscles. In a majority of cases, myofascial pain is a primary cause of regional pain. Myofascial pain is muscle tenderness that arises from hyper sensitive trigger or focal points, found at multiple sites in a muscle and the fascia of muscle tissue. Qualities of Trigger Points Trigger points have a number of qualities - potential, active, latent, and also as key/satellites either primary or secondary. Trigger point maps can be made that are accurate relative to patient’s complaints. Active trigger point is one that refers pain either locally or to another location (usually in the body along nerve pathways). Latent trigger point is one that exists, but does not refer pain until pressure or strain is applied to the myoskeletal structure containing such a trigger point. Latent trigger points can influence muscle activation patterns, resulting in poor muscle coordination and balance. Active and latent trigger points are also known as "ouch” points, when they provoke a painful response in a patient. Key trigger point is a pain referral pattern along a nerve pathway that either creates or activates a latent trigger point on the pathway. Satellite trigger point is one which is activated by a key trigger point. Successful treatment of a key trigger point will often affect the satellite trigger point, resolving it or changing it from active to latent.

Primary trigger point can cause activation of a secondary trigger point in another structure. Treating such a primary trigger point does not affect the secondary trigger point. Activation of such trigger points can be caused by a number of factors such as muscle overload, activation by other trigger points (key/satellite, primary/secondary), disease, psychological stress, direct trauma to the area, accident trauma (i.e. - car accident which over-stresses many muscles and causes instant trigger points), radiculopathy, infections and such health issues as smoking. Clinical note: I have found a strong correlation between a long extended sitting posture, often combined with mouse/keyboard computer use, and trigger points found in the neck and back areas. The creation of such trigger points, in my opinion, are often due to a combination of poor body posture, muscle fatigue, and a bad ergonomic setup.

19

Trigger points form only in muscles, found as a local contraction in a small number of muscle fibers in a larger muscle or muscle bundle. This contraction can pull on the tendons and ligaments associated with the muscle, causing pain deep within a joint, even where there are no muscles. When these muscle fibers contract, they use up the biochemical energy, which over time results in fatigue and ultimately a toxin buildup such as lactic acid. In addition, such tightened muscle fibers constrict capillaries and prevent them from carrying off the fatigue toxins to the body's organ systems to be recycled. This buildup of toxins in a muscle bundle or muscle forms feels like a tight muscle or band. When trigger points are present in muscles, pain and weakness is often present in the associated structures. These pain patterns in muscles follow specific nerve pathways and have been mapped. This allows for identification of the causative pain factor. Many trigger points have pain patterns that do overlap. Some create reciprocal cyclic relations and necks need to be treated to resolve them. Diagnosis of Trigger Points When there is a taut band in muscles a hard nodule can be felt and a trigger point can be identified. A twitch response upon goading (finger running back and forth perpendicular to the muscle's direction) will often activate the "all or nothing" response in a muscle that causes it to contract. Pressing on the same point on an affected muscle can often refer pain. Clusters of trigger points are not uncommon in some of the larger muscles, such as the gluteus group. Heat differential in the local area of a trigger point is usually present, which can be felt or imaged, and can aid in the diagnosis of such a trigger point. Referred pain from trigger points often mimics the symptoms of a long list of common patient complaints, but health professionals rarely consider a myofascial cause. Most common everyday pain can be caused by myofascial trigger points and that failure to diagnose can lead to ineffective treatment and patient frustration. A recent study of physical therapy students revealed higher prevalence of active trigger points in the right Trapezius and Levator Scapula muscles, and higher prevalence of latent trigger points in the left Sternocleidomastoideus and Levator Scapula muscles during exams, as well as a higher rate of tenderness in suboccipital musculature.

Some common muscle trigger points found in certain neck conditions:

Muscles: Symptoms:

Pterygoid, sternocleidomastoid, posterior digastric Nighttime sinus issues

Pterygoid, sternocleidomastoid Post nasal drip / Drippy nose

Sternocleidomastoid Dizziness on turning head /

Vision issues

Levator scapulae Neck Stiffness

Trapezius, splenii, suboccipital, semispinalis capitis, Headaches frontalis, sternocleidomastoid, temporalis, zygomaticus major

Temporalis, masseter, digastric TMJ issues

20

Pterygoid, sternocleidomastoid, master Ear ringing, itching, pain

Temporalis, sternocleidomastoid, trapezius, Various eye issues splenius cervicis

Additional Neck Tests Usually a thorough history taking and physical examination will help diagnose many neck conditions; however, when additional medical information is needed or pathology needs to be ruled out, specialized tests can be performed. More common tests include X-ray studies, computerized tomography (CT), magnetic resonance imaging (MRI), sensory evoked potentials (SEPs), and electromyography (EMG). Arthrography is often used to help diagnose unexplained joint pain. A contrast iodine solution is injected into the joint area to outline the joint structures, such as the ligaments, cartilage, tendons and joint capsule. Several X-ray(s) of the joint are then taken in different positions, using a fluoroscope to analyze the joint structural integrity. Laboratory studies of blood, urine or joint (synovial) fluids are used to identify the presence and amount of substances which can rule in or out “Red Flags” such as infection or tumor. For example, high amounts of uric acid in the blood can indicate gout. High white blood cell count in joint fluid may indicate severe inflammation or infection. Bone Scan can rule out various bone disorders. One type tests the density of the bone and is used to help diagnose osteoporosis. The second type of bone scan is used to identify areas where there is abnormal bone formation, usually due to stress fractures, arthritis, infection, or cancer. CT scan (computed tomography) is an X-ray combined with computer technology to produce a more detailed, cross-sectional image of your body. CT scan is useful to rule out tumor or a fracture that is not visible on plain film X-ray(s) or if history of severe trauma to the abdomen, pelvis or spinal cord has occurred. Dual-energy X-ray absorptiometry (DEXA) is the most widely used test for measuring bone density. It can monitor changes in bone density in patients with osteoporosis who are undergoing treatments. This test takes a picture of the bones in the spine, neck, total body and wrist and calculates their density. Your bone density and risk of fracture are compared to the "normal" range for people your age as well as to the maximum bone density possible. MRI (magnetic resonance image) can be used to help diagnose the integrity of the muscles, ligaments and cartilage, herniated disks, and to rule out major pathology. The dynamic MRI exam demonstrated a major number of findings and spinal cord compressions compared to the static MRI exam. The dynamic MRI can provide useful information in patients, but be careful of the evaluation of the findings in the extension MRI exam as they are probably over-expressed. MRI studies show a high incidence of CSTEH (Cervical spine traumatic epidural hematomas) among trauma patients. CSTEH is associated with significant morbidity and mortality. High clinical vigilance is required to allow the request and acquisition of urgent magnetic resonance imaging to diagnose CSTEH, as the entity is often not evident on initial cervical spine computed tomography investigations. Clinical Note: MRI is usually diagnostic if plain X-ray(s) and conservative therapy prove to be ineffective.

21

Electromyography (EMG), also known as nerve conduction studies, can be useful to separate motor unit problems. An electromyograph detects the electrical potential generated by muscle cells when these cells are stimulated electrically or neurologically. The signals can be analyzed to detect certain medical abnormalities such as neuropathic or myopathic diseases and to assess tissue insult or nerve impairment. Neuropathic disease has the EMG findings of abnormal action potential amplitude due to reinnervation of denervated fibers. The action potential amplitude is twice normal due to the increased number of fibers per motor unit. Also found is an increase in duration of the action potential along with a decrease in the number of motor units in the muscle. Myopathic disease has a decrease in duration of the action potential, a reduction in the area to amplitude ratio of the action potential, and a decrease in the number of motor units in the muscle (found in extremely severe cases only). Clinical Note: This type of testing (EMG) is helpful to identify local neurological dysfunction in patients with neck symptoms lasting more than three to four weeks. Due to the individuality of each patient and disease, some of these characteristics may not appear in every case. Abnormal results may be caused by certain medical conditions as well as improper testing.

References:

Books Consulted: Myofascial Pain and Dysfunction: The Trigger Point Manual, Volume 2 Janet G. Travell, (Author) David G. Simons (Author) Guides to the Evaluation of Permanent Impairment, Fifth Edition Gunnar B. J. Andersson (Author, Editor), Linda Cocchiarella (Author, Editor) Occupational Medicine Practice Guidelines: Evaluation and Management of Common Health Problems and Functional Recovery of Workers Lee S., M.D. Glass (Author), Jeffrey S. Harris (Author), Bernard R., M.D. Blais (Contributor), Elizabeth, M.D. Genovese (Contributor), Michael N., M.D. Goertz (Contributor) Management of Common Muscular Skeletal Disorders Randolph M. Kessler(Author) Fundamentals of Chiropractic Diagnosis and Management Dana J. Lawrence (Author) Web Sites Consulted: http://www.ncbi.nlm.nih.gov/pubmed http://www.chiroaccess.com https://www.ncbi.nlm.nih.gov/pubmed/29268305 https://www.ncbi.nlm.nih.gov/pubmed/29284446

22

https://www.ncbi.nlm.nih.gov/pubmed/28167166 https://www.ncbi.nlm.nih.gov/pubmed/?term=Static+and+dynamic+cervical+MRI%3A+two+useful+exams+in+cervical+myelopathy https://www.ncbi.nlm.nih.gov/pubmed/?term=Shoulder+pain+due+to+cervical+radiculopathy%3A+an+underestimated+long-term+complication+of+herpes+zoster+virus+reactivation%3F