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CLINICAL ANATOMY, KINESIOLOGY,
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AND BIOMECHANICS
ere is some irony in the fact that the cervical spine
anatomy is so complex, but that risk factors and data
from imaging studies suggest we de-emphasize the role of
pathoanatomy in neck pain. Nevertheless, important insights
can be gained from understanding the unique anatomical
features of the cervical spine. In fact, many exercises and
manual therapy interventions for neck pain point to regional
approaches, particularly treatment of the thoracic spine, and it
might be through an understanding of functional anatomy that
this regional treatment approach can make sense.
Cervical Vertebrae and Discs
e cervical spine consists of 7 cervical vertebrae, 3 of
which are classified as atypical.
(C2), and C7 are morphologically and functionally different
than C3-6, and so we will consider these atypical vertebrae on
an individual basis. In general, in contrast to the lumbar and
thoracic vertebrae, cervical vertebrae are smaller with a relatively
larger vertebral canal affording more space for the robust
spinal cord, and thickenings for the brachial plexus. Cervical
vertebrae are also unique in that the transverse processes
contain a transverse foramen in which the vertebral arteries
ascend from the subclavian artery into the cranium. Cervical
discs are also unique in that they do not have a true annulus
fibrosus ring around the entire periphery of the disc. Instead,
the disc essentially consists of an anterior and posterior annular
band, which thins greatly around the uncovertebral joints. e
uncovertebral joints also remind us that the cervical vertebrae
do not have smooth surfaces on the vertebral body, but that
the end plates are complex, nuanced, and uneven structures.
is contributes to the fact that coupled movements and
biomechanics of the cervical spine are poorly understood and
that segmental movement of the cervical spine is nuanced and
complex.
13
Age-related morphologic changes to the cervical disc
Cervical discs undergo a particularly curious evolution
during normal aging. In fetuses and newborns, uncinate processes
and uncovertebral joints are not present. ese protuberances
and joints appear around age 9 during childhood. By around
age 33, the uncovertebral joints have become morphologically
distinct, and communicate with the cervical intervertebral disc
forming a transected line that divides the annulus fibrosus in
the cervical spine into anterior and posterior portions.
has implications as it relates to normal degenerative changes
in the cervical spine. e uncovertebral joints can develop
osteoarthritic changes similar to other peripheral joints,
including the development of bony spurs, osteochondral cysts,
and thinning. While cervical intervertebral discs are naturally
reinforced anteriorly by the anterior longitudinal ligament,
and to a lesser extent the posterior longitudinal ligament
11,12
e atlas (C1), the axis
14
is
posteriorly, bone spurs and disc herniations can occur along the
transected line causing central and foraminal stenotic changes.
15
Because not all degenerative changes result in pain, the overall
impact of the extent of degenerative morphologic changes
on pain symptoms remains unclear. For example, up to 57%
of asymptomatic people age 65 and older will demonstrate
degenerative changes in the cervical spine with imaging.
15,16
Atypical Cervical Vertebrae
e atlas (C1) is a ring-like vertebra lacking a spinous
process. e atlas has 2 lateral masses that are concave on the
superior aspect to receive the occipital condyles. e axis (C2)
is unique for the presence of the odontoid process or dens. e
dens is a superior peg-like projection and is a vestigial remnant
of the C1 vertebral body. e final atypical cervical vertebra is
C7, which has a long spinous process, which is not bifid, as are
the other cervical vertebrae’s spinous processes. Both C1 and
C2 allow for very specific movement and these will be discussed
later. ere are 3 articulations of the atlanto-axial (AA) joint.
e 2 lateral articulations between the inferior surfaces of the
lateral masses of C1 and the superior facets of C2 are planartype synovial joints. e third articulation is the median AA
joint between the dens of C2 and the anterior arch of C1, which
functions as a pivot-type synovial joint.
Ligaments of the Cervical Spine
e lower cervical spine contains many of the same
ligamentous structures found throughout the rest of the spine,
including the anterior longitudinal ligament, the posterior
longitudinal ligament, interspinous ligaments, supraspinous
ligament, ligamentum flava, and intertransverse ligaments.
e nuchal ligament is unique to the cervical spine. It is a
thickening from the occiput to the spinous processes of C3-5,
where it merges with the supraspinous ligament. e nuchal
ligament serves as an attachment point for several muscles.
Many cervical muscles have very small attachment points and
suffer from small mechanical advantage as the spinous processes
are shallow in the upper and middle portion of the cervical
spine. e nuchal ligament helps overcome this challenge by
providing a broad expanse for attachments and therefore, larger
muscular mechanical advantage.
e upper cervical spine is a region with unique ligamentous
structures that include the: transverse, alar, apical, and cruciate
ligaments and the tectorial membrane. Clinically, the ligaments
of most concern are the transverse and alar ligaments as well
as the tectorial membrane. e transverse ligament is a thick
fibrous band that functions to hold the dens firmly anterior to
the vertebral canal and against the anterior arch of the atlas,
thus prohibiting any interaction of the dens with the spinal
cord. e transverse ligament along with the much less stout
vertically oriented superior and inferior connective tissue bands
that project from the transverse ligament to attach to the occiput
and C2 vertebra, respectively, form the cruciate ligament of the
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9
cervical spine, so named for its shape resembling a cross. e
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alar ligaments connect the lateral aspects of the dens to the rim
of the foramen magnum on the occiput. ey are short, round
cords and function to limit rotation and link C2 to the occiput,
17
forming a functional linkage for the upper cervical spine.
e
tectorial membrane is a strong extension from the posterior
longitudinal ligament. It broadens and passes over the median
AA joint to attach on the floor of the intracranial portion of the
occipital bone. Disruptions of the transverse or alar ligaments
can result in significant instability of the craniovertebral region
18
and potential neurologic injury or signs and symptoms.
e
tectorial membrane is most often injured in pediatric patients
following high speed collisions and can result in neurologic
symptoms during flexion and extension movements.
Muscles of the Cervical Spine
e cervical spine musculature is best understood by
dividing the muscles into anterior and posterior/lateral groups,
and then subsequently superficial, deep, and even deeper layers.
e primary function of the superficial layer is to create global
movements of the head, scapula, and clavicle. e deeper
musculature can be understood to provide control of movement
and stability as the body and head move about in space.
Anterior cervical muscles
Supercial layer: e sternocleidomastoid (SCM) muscle
has attachments from the anterior surface of the manubrium
and upper surface of the medial third of the clavicle to the
lateral surface of the mastoid process and the lateral half of
the superior nuchal line of the occiput. e unilateral action
draws the head toward the ipsilateral shoulder and rotates the
head to the opposite side. When working together, the 2 SCM
muscles extend the head moving it into a forward neck position.
e SCM muscles can also assist in respiration by raising the
clavicles when the head is fixed.
Deep layer: e deep anterior muscles of the upper cervical
spine include the rectus capitis lateralis, rectus capitis anterior,
longus capitis, and some fibers of the longus colli muscles (Table
1). e rectus capitis lateralis muscle has attachments to the
occipital bone at the jugular process and the transverse process
of C1. is muscle contributes to flexion and stabilization of
the head when working bilaterally, and rotation to the opposite
side when acting unilaterally. e rectus capitis anterior muscle
has attachments on the base of the occipital bone in front of the
occipital condyle to the lateral mass of C1. e rectus capitis
anterior muscle flexes the head at the C0-1 articulation. e
longus capitis muscle has attachments on the basilar part of
the occipital bone and the anterior tubercles of the transverse
processes of the C3 through C6 vertebrae. e longus capitis
muscle, with the rectus capitis anterior muscle, flexes the head.
e longus colli muscle has multiple attachments on the bodies
and transverse processes from C1-7 and T1-3. e action is to
flex and assist in contralateral rotation of the cervical spine.
Posterior/lateral cervical muscles
Supercial layer: e trapezius muscle extends from the
superior nuchal line and external occipital protuberance to the
ligamentum nuchae, spinous process of C7, and apex of the
scapular spine. e muscle is divided into upper, middle, and
lower portions. Some considerations about the trapezius muscle
relevant to the cervical spine include the following:
• e upper portion of the trapezius, while extremely thin, is
the most clinically and functionally significant to the cervical
spine
• e middle portion originates from the spinous process of C7
• Combined, the 3 sections of the trapezius muscle has the
largest attachment area in the body
• It is innervated by the accessory nerve (cranial nerve XI) and
the ventral rami of the 3rd and 4th spinal nerves
• e greater occipital nerve often travels through the upper
trapezius muscle on its way to the scalp, and can become
entrapped in this muscle
Functionally the trapezius muscle can perform a variety of
motions depending on which body part is stabilized and which
is permitted to move. ese include scapular elevation and
retraction, head/neck ipsilateral side flexion and contralateral
rotation, and accessory breathing through shoulder elevation.
When the trapezius muscles of both sides of the body work
together they can assist with cervical extension. Paying close
attention to all these motion components is critical when
attempting to stretch this muscle.
e levator scapulae muscle has its proximal attachments
on the posterior tubercles of transverse processes of the C2
through C6 vertebrae. With the rhomboid minor muscle (and
its proximal attachments on the ligamentum nuchae and the
spinous processes of C7 and T1), the levator scapulae contributes
to cervical spine mechanics but is primarily discussed in terms
of action on the scapula.
More laterally, the scalene muscles are divided into anterior,
middle, and posterior portions, each of which has a dual action.
e anterior scalene muscle has attachments from the anterior
tubercles of the transverse processes of the C3 through C6
vertebrae, to the 1st rib. If the neck is fixed, the action is to
elevate the 1st rib. If the 1st rib is fixed, the action is to laterally
flex the neck to the same side and rotate the cervical spine to
the opposite side. e middle scalene muscle has attachments
on the posterior tubercles of the transverse processes of the C5
through C7 vertebrae and the upper surface of the 1st rib. If
the neck is stabilized, the action is to elevate the 1st rib. If the
1st rib is fixed, the action is to laterally flex the neck to the
same side. e posterior scalene muscle has attachments on the
posterior tubercles of the transverse processes of the C5 through
C7 vertebrae and the upper surface of the 2nd rib. If the neck
is fixed, the action is to elevate the 2nd rib. If the 2nd rib is
fixed, the action is to laterally flex the neck to the same side.
10
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Table 1.
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Anterior Muscles of the Cervical Spine*
Muscle Origin Insertion Innervation Action
Lateral surface of
mastoid process of
temporal bone, lateral
Sternocleidomastoid
half of superior nuchal
line of occipital bone
Rectus capitis lateralis Occipital bone at
jugular process
Rectus capitis anterior Base of cranium
anterior to occipital
condyle
Basilar aspect of
Longus capitis
occiput
Anterior tubercle of
Longus colli
C1, bodies of C1-3,
transverse processes of
C3-6
*Adapted from Moore et al.
129
Supercial Layer
Sternal head: anterior
surface of manubrium
of sternum
Clavicular head:
superior surface of
medial third of clavicle
Deep Layer
Transverse process of
C1 (atlas)
Anterior lateral mass
of atlas
Anterior tubercle of
transverse processes of
C3-6
Bodies of C5-7 and
T1-3, transverse
processes of C3-5
Spinal accessory nerve
(cranial nerve XI); C2
Branches of C1 and
C2 spinal nerves
Branches of C1 and
C2 spinal nerves
Anterior rami of C1-3
spinal nerves
Anterior rami of C2-6
spinal nerves
Unilateral action:
ipsilateral lateral
flexion and
contralateral rotation
Bilateral action: upper
cervical extension with
lower cervical flexion
Head flexion and
stabilization
Work together to flex
the head
Unilateral action:
contralateral rotation
Bilateral action:
cervical spine flexion
e posterior scalene also can provide a rotation movement of
the cervical spine to the ipsilateral side. But, functionally, the
rotational action of all scalene muscles is likely most potent
when the head is already rotated to one side, to provide rotation
back toward a more neutral neck position.
Deep layer: On the posterior aspect of the cervical spine,
the splenius capitis, the splenius cervicis, and the semispinalis
capitis and cervicis muscles provide control of neck extension.
e splenius capitis muscle has attachments from the lateral
superior nuchal line and mastoid process to the lower half of
the ligamentum nuchae, and the spinous processes of C7 and
T1-3 vertebrae. e splenius cervicis has attachments from the
posterior tubercles of the transverse processes of C1 through C3
vertebrae to the spinous processes of T3-6. Acting bilaterally,
these muscles extend the cervical spine. Acting unilaterally, they
laterally flex and rotate the head to the same side.
e semispinalis capitis and cervicis are found deep to the
splenius capitis and cervicis, and just superficial to the deep
suboccipital muscles, which are discussed next. e semispinalis
muscles act together with the splenius muscles to extend the
head and cervical spine. e greater occipital nerve (C2) pierces
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this muscle. Entrapment of this nerve in the semispinalis
cervicis muscle can lead to greater occipital neuralgia.
e deepest layer of the posterior upper cervical spine
muscular anatomy consists of the short suboccipital muscles
that cross 1 to 2 vertebral levels. ese include the rectus capitis
posterior major, rectus capitis posterior minor, obliquus capitis
inferior, and the obliquus capitis superior muscles. e rectus
capitis posterior major has attachments to the spinous process
of the axis (C2) and the lateral part of the inferior nuchal line of
the occipital bone. e action is extension and rotation of the
head to the same side as the muscle. e rectus capitis posterior
minor has attachments to the posterior tubercle of the atlas
(C1) and the occipital bone at the medial part of the inferior
nuchal line and just below the inferior nuchal line between
the line and the foramen magnum. e action is to extend the
head at the atlanto-occipital (OA) joint. e obliquus capitis
inferior has attachments from the C2 spinous process to the
C1 transverse process. e action is to rotate the atlas and skull
around the odontoid process of the axis (C2), to the same side.
e obliquus capitis superior has attachments on the transverse
process of the atlas (C1) and to the occipital bone between the
11
inferior and superior nuchal lines. e action is extension and
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lateral flexion of the head to the same side. Table 2 reviews the
deep posterior and lateral muscles of the cervical spine.
Neurovascular Structures in the Cervical Spine
e cervical spine contains several major arterial supplies
to the cranium. e common carotid arteries originate from
the subclavian arteries. e common carotid artery bifurcates
into the internal carotid and external carotid arteries near the
level of the jaw. Of interest, the carotid body or carotid sinus,
which senses blood pressure and oxygenation levels is located at
the level of this bifurcation. e internal carotid artery supplies
blood to the brain (later becoming the anterior and middle
cerebral arteries) while the external carotid artery supplies blood
to the face, neck, and cervical spine.
e smaller vertebral arteries originate from the subclavian
artery and travel through the cervical spine via the transverse
foramen. e vertebral artery enters this space anywhere between
C6 and C4. e vertebral artery makes a torturous move at C2,
where it curves sharply behind the superior articular process
of the atlas, before ascending into the brain via the foramen
magnum, joining with the opposite side vertebral artery to form
the basilar artery at about the level of the pons. ere is debate
about how much cervical movements, rotation and extension
particularly, impact the vertebral arteries, and newer modeling
suggests movement has relatively little impact on blood flow.
Given the close relationship with the spine, the vertebral arteries
can be easily impacted by osteophytes or vascular disease.
19,20
From a nervous system perspective, the cervical spine
gives rise to the cervical and brachial plexuses. e cervical
Table 2.
Posterior/lateral Muscles of the Cervical Spine*
Muscle Origin Insertion Innervation Action
Trapezius Medial third of
superior nuchal line,
external occipital
protuberance, nuchal
ligament, spinous
processes of C7 and
T1-12 vertebrae
Levator scapulae Posterior tubercles
of C2-6 transverse
processes
Anterior scalene C3-6 transverse
processes
Supercial Layer
Lateral third of the
clavicle, acromion,
Spinal accessory nerve
(cranial nerve XI); C2
spine of the scapula
Superior aspect of
medial scapular border
Dorsal scapular n.
(C5) and C3 and C4
spinal nerves
First rib Cervical spinal nerves,
C4-6
Unilateral action:
ipsilateral neck flexion
Bilateral action: neck
extension
Downward scapular
rotation (primarily)
Unilateral action:
elevates first rib,
ipsilateral lateral
flexion if rib is
stabilized
Bilateral action: head
130
flexion
Middle scalene Posterior tubercles
Posterior scalene Posterior tubercles
of C5-7 transverse
processes
of C5-7 transverse
processes
Superior surface of
first rib
Superior surface of
second rib
12
Anterior rami of spinal
nerves, C3-8
131
Elevates first rib,
ipsilateral lateral
flexion if rib is
stabilized
Anterior rami of C7
and C8 spinal nerves
Elevates second rib,
ipsilateral lateral
flexion if rib is
stabilized
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Table 2.
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Continued
Muscle Origin Insertion Innervation Action
Splenius capitis
Nuchal ligament,
spinous processes of
C4-T7 vertebrae
Deep Muscles
Mastoid process and
occipital bone
Dorsal rami of cervical
spine nerves, C3-6
Unilateral action: ipsilateral lateral flexion
and rotation
Splenius cervicis
Spinous process of
T3-6
Semispinalis capitis
132
Occiput between
superior and inferior
nuchal lines
Semispinalis cervicis Spinous processes of
C2-5
101
133
Lateral aspect of
inferior nuchal line
Medial portion of
inferior nuchal line
Inferior aspect of the
tip of the atlas (C1)
Rectus capitis
posterior major
Rectus capitis posterior
minor
Obliquus capitis
inferior
transverse process
Transverse process
C1-3
Articular processes
of C5-8, transverse
processes of T1-6
Transverse processes
of T1-6, articular
processes of C4-7
Deeper “Suboccipital” Muscles
Spinous process of axis
(C2)
Tubercle on posterior
arch of atlas (C1)
Base of spinous process
and lamina of axis
(C2)
Greater occipital nerve
Dorsal rami of cervical
spinal nerves
Suboccipital nerve,
dorsal ramus of C1
nerve
Bilateral action: head
and neck extension
Unilateral action:
contralateral head and
neck rotation
Bilateral action: head
and neck extension
Ipsilateral rotation of
atlantoaxial joint
Head extension
Ipsilateral rotation of
atlantoaxial joint
Obliquus capitis
superior
*Adapted from Moore et al.
plexus forms from the ventral rami of C1 to C4. It is known
to anastomose with the facial nerve, hypoglossal nerve, spinal
accessory nerve, vagus nerve, and the sympathetic trunk. It lies
anteromedial to the scalene muscles but is deep to the SCM
muscle. e brachial plexus arises from nerve roots C5-8 and
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Between superior and
inferior nuchal line of
occipital bone
129
Superior surface of the
transverse process of
atlas (C1)
T1. It is important to recognize that injuries to the cervical
spine, spinal cord, or nerve plexuses are all possible and should
be considered when evaluating patients with cervical spine
injuries, particularly those injuries with traumatic mechanisms.
13
Unilateral action:
ipsilateral lateral
flexion
Bilateral action: head
extension
21
Kinesiology and Biomechanics for the Cervical Spine
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Motion of the head and neck is achieved both through
the atypical vertebrae of the craniovertebral junction and by
collaborative action of the typical cervical vertebrae. Like any
region of the spine, the orientation of articular surfaces and
facet joints dictates the type, amount, and direction of motion
available.
e primary motion at the OA joint is in the sagittal plane.
e OA joint provides about 15-20° total flexion/extension
motion, with the majority occurring into extension at about
a 2:1 ratio. Variable reports reveal about 5-8° of side flexion
motion in each direction is also available at this joint, although
13
other sources indicate no side flexion is possible.
In contrast,
motion at the AA joint is almost all rotational in the horizontal
or transverse plane, although some flexion and extension
motion is possible. e AA joint alone accounts for around
11
50% of total neck rotation.
Table 3 outlines the relative
motion contributions of various cervical regions.
Concerning the typical cervical vertebrae (C3-6), the facet
joints are masters of compromise, allowing for some motion in
all directions. e facets are oriented on a 45° angle between
the frontal and sagittal plane, allowing for significant amounts
of motion in 3 planes, unlike other regions of the spine. e
lower region of the spine accounts for 75% of motion in the
sagittal plane and 50% of rotation. In general, flexion motions
occur from an anterior and superior movement as a reflection of
sliding or “opening” of the facet joints, while extension occurs
from “closing” of these joints which is a posterior and inferior
movement. Rotation and side flexion occur in various amounts
from combining these opening and closing motions. Extension
Table 3.
Relative Contributions of Cervical Range of Motion by Functional
Segment*
Segment/Joint
Sagittal Plane
(Flexion/Extension)
Transverse Plane
(Rotation)
Flexion: 5°
C0-1 (OA)
Extension: 10°
Negligible 5°
Total: 15°
Flexion: 5°
C1-2 (AA)
Extension: 10°
35-40° None
Total: 15°
Flexion: 35-40°
C2-7
Extension: 55-60°
30-35° 30-35°
Total: 90-100°
Total 120-130° 65-70° 35-40°
Values for transverse and frontal plane motion are for each direction.
*Adapted from Neumann.
11
and ipsilateral side flexion and rotation approximate the facet
joints or “close” them, while contralateral side flexion, rotation,
and flexion “open” or flex the facet joints. It should be noted
that limitations in motion occur not only from arthrokinematic
dysfunctions, but also from connective tissue restrictions as
well. For example, the primary limitation of cervical extension
motion is the approximation of the articulations of the facet
joints, while flexion is limited by the ligamentum nuchae,
interspinous ligaments, and by compressive resistance from the
anterior aspect of the annulus fibrosus of the disc.
All spinal motion segments have coupled motion, meaning
that movement in 1 plane results in obligatory movement in
22
another plane.
is occurs because the facet joints allow more
than 1 degree of freedom and are not oriented in an exact plane.
In the cervical spine, the 45° orientation of the facet joints for
segments C3-7 result in motion that is coupled ipsilaterally,
meaning rotation to the right also produces some degree of side
11
flexion to the right.
While coupled motion can be complex,
and not always predictable, the cervical spine segments ipsilateral
coupling is the most accepted motion model for spinal coupling
23
patterns.
But astute examiners may note that when requesting side
flexion or rotation to one side, many individuals are able to
produce this motion with little to no observable obligatory
rotation or side flexion of the face and eyes. is is not because
the C3-7 segments did not rotate or move in side flexion, but
it is because these coupling movements in the lower cervical
spine were concealed by contralateral coupling at the OA and
AA joints. is combined ipsilateral and contralateral coupling
allows us to maintain level gaze through a complex combination
of movements. is leveling of the
eyes occurs subconsciously through
complex coordination of small
muscles. erefore, this motion
pattern underscores the need to
address motion limitations in all
degrees of freedom for patients
Frontal Plane
(Side Flexion)
with cervical dysfunction, and the
need for a thorough evaluation of
motion in both the upper and lower
cervical spine when level gaze is not
maintained during active range of
motion (ROM) assessment.
Finally, we should point out the
relationship of movement between
the thoracic and cervical spine. We
will discuss that many interventions
for the cervical spine will include
treatment at the thoracic spine. An
appreciation of the soft-tissue and
muscular interplay of these regions
is necessary to begin to understand
this. e trapezius, levator scapulae,
14
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rhomboids, scalenes, and various spinal segment muscles
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inherently link motion of the thoracic spine, scapulae, and
even the arms to cervical movements. erefore, movement
dysfunction in one area can result in regional movement
dysfunction. It is not uncommon to perform a manual technique
to the thoracic spine that results in an increased in cervical
motion. is is, in part, due to these functional anatomical
relationships, but likely involves more complex neurological
24–29
effects as well.
CLINICAL EXAMINATION AND
DECISION-MAKING PROCEDURES
Modern conceptualization of the diagnostic and clinical
reasoning process demands that, in addition to the patient’s
history, prevalence of the disorder, and risk factors, other factors
such as demographic and comorbidities also be considered
when forming hypotheses upon which to base examinations
and interventions. erefore, we begin this section discussing
prevalence and risk factors, with the added benefit that we
can follow along closely with the organization of the clinical
guidelines by Blanpied et al.
in general, we will explore risk factors and decision-making
specific for vascular pathologies of the neck (previously referred
to as cervical artery dysfunction [CAD]) before moving into
traditional cervical examination information.
Neck pain is common, with up to 54% of the population
reporting experiencing neck pain within the previous 6 months.
It is among the top 5 causes of disability and the clinical course is
8
variable.
Somewhere around 30% of people with neck pain will
that the prevalence of neck pain is increasing world-wide.
In acute traumatic conditions (whiplash and associated
disorders [WAD]), clinicians can expect individuals to
follow 1 of 3 likely trajectories: mild problems with rapid
recovery (approximately 42% of individuals depending on
the measured outcome), moderate problems with some but
incomplete recovery (approximately 40% of individuals),
and severe problems with no recovery (approximately 17% of
30–33
individuals).
Interestingly, WAD recovery trajectories can
vary widely: individuals in the same motor vehicle collision, can
experience different recovery trajectories, and collision factors
(speed, direction, etc) do not seem to be strong predictors
of recovery or persistent pain.
at risk factors for the development of chronicity for patients
with WAD. Five factors, when measured within 6 weeks of
onset, have been shown to be strong predictors of chronicity:
(1) high pain intensity, (2) high self-reported disability (Neck
Disability Index [NDI]), (3) high pain catastrophizing, (4) high
acute posttraumatic stress symptoms, and (5) cold hyperalgesia
(Table 4).
Risk factors for non-traumatic neck pain are variable based
on the type of neck pain. Female sex and prior history of neck
pain are the strongest and most consistent risk factors for new-
8
Once we understand risk factors
4
ere is evidence
34
Alternatively, we can look
Table 4.
Prognostic Factors and Associated Tools to
Determine Risks of Prolonged Recovery After Whiplash and Associated Disorders (WAD)*
Construct Recommended Tool
High pain
intensity
High self-reported
disability
High pain
catastrophizing
High acute
posttraumatic
stress syndrome
Numeric pain rating (0-10):
rating >6/10
Neck Disability Index: score
>30%
Pain Catastrophizing Scale:
score >20
Impact of Events Scale Revised: score >20 predicts
symptom chronicity
Cold hyperalgesia TSA-II - NeuroSensory
Analyzer: gold standard
Alternatives: cold endurance
with ice cube or cold metal
bars
*Adapted from Blanpied et al.
onset neck pain in office workers and the general population.
8
2,9
Older age, high job demands, smoking history, low social/work
support, and prior history of low back pain may also be risk
factors. Older age and a prior history of other musculoskeletal
disorders were predictors for chronic symptoms.
31
Screening for Serious Conditions
Paramount to any examination or intervention of the
cervical spine lies the responsibility of the provider to screen for
and rule out serious medical conditions. Given the confluence
of critical anatomical structures in the craniocervical region,
there is potential for significant clinical conditions to occur,
and therefore potential negative consequences for a failure to
conduct a thorough assessment. Of primary concern for the
cervical spine is ruling out spinal fractures, assessing risk for
vascular pathologies of the neck, assessing ligamentous stability,
and malignancy.
35
We can consider these priority conditions to
always consider, even if the true prevalence of these disorders
presenting to physical therapy settings is low.
35
Patients
presenting with neck pain may also present with concurrent
headaches, dizziness, and concussive symptoms, especially after
trauma. Full discussion of these conditions falls outside the
scope of this monograph, however, recognition that patients
with neck pain may present with conditions that require referral
and medical team management is critical. Cervical myelopathy,
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15
depending on severity of neurologic symptoms can also be
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considered a serious condition, and this condition will be
discussed later in the monograph.
Fractures
Decision-making algorithms have been developed that
help providers encountering patients after acute trauma to
identify the need for a radiograph. In the cervical spine, both
the Canadian Cervical Spine Rules and the Nexus Criteria are
acceptable rules that are sensitive and serve as good screening
36–38
tools.
Providers should note that the rules were developed
for acute trauma and alert patients, and identify significant
cervical injuries that require surgical or other stabilization
and so include not only fractures but dislocations or severe
ligamentous instability as well. e clinician should always
rely on sound clinical reasoning and multiple data points to
decide the level of concern for fractures and need for imaging
referral. A standard cervical spine radiograph series includes
anterior-posterior, lateral, and odontoid views as recommended
by the American College of Radiology.
39
Cervical spine endrange flexion and extension views, previously a technique used
to visualize instability, are no longer recommended as they
are often inadequate at imaging any instability due to various
40,41
factors.
It is also possible that individuals with undetected
cervical fractures present in a non-acute manner to a physical
therapy setting.42 An additional resource for more information
for appropriate use of imaging is the American College of
Radiology Appropriateness Criteria website at https://www.
acr.org/Clinical-Resources/ACR-Appropriateness-Criteria. is
resource helps clinicians identify optimal imaging by condition.
Vascular problems
ere is a range of arterial dysfunction that can impact the
cervical spine, and recent literature suggests it is possible for
vascular pathologies of the neck to present with symptoms similar
43–47
to musculoskeletal neck pain.
e International Framework
for Examination of the Cervical Region for potential of vascular
pathologies of the neck prior to orthopaedic manual therapy
(OMT) intervention (International Federation of Orthopaedic
Manual Physical erapists [IFOMPT] Framework, 2020)
provides a useful and thorough basis for making decisions
about risk and assessment of vascular pathologies of the neck.19
e IFOMPT Framework first draws a helpful distinction
between risk at an epidemiologic versus individual level. is
is significant in that while the overall incidence of vascular
pathologies of the neck in physical therapy settings is low, risk
at an individual level can vary greatly, and so physical therapists
should carefully analyze risk factors on this individual level,
even as epidemiologic risk is considered.
46,47
Table 5 reviews the
common vascular pathologies possible in this body region along
with typical symptom presentations.
Note that neck pain is a particularly common symptom
presentation for a variety of vascular pathologies (Figure 1).46
us, it is important to recognize not only symptoms and
critical, if not sometimes subtle, items in the patient history,
but also those clinical presentations or factors that elevate a
patient’s risk of presenting with vascular abnormalities. Similar
to other cardiovascular conditions, vascular pathologies are
often multifactorial scenarios. While individual risk factors are
important to note, the presence of multiple risk factors should
elevate the clinician’s suspicion of vascular pathology.
46,47
Not
surprisingly, some risk factors are identical to cardiovascular
disease, such as hyperlipidemia, history of smoking, and
hypertension.
48–51
Additionally, recent trauma or infections
of the head and neck can be risk factors for cardiovascular
48–51
disease.
It is also helpful to explore physical findings and signs
specifically related to vertebral artery events and internal carotid
Table 5.
Symptom Association with Vascular Pathologies of the Neck*
Structure/Site Pathology Symptoms/Presentation
Carotid artery Atherosclerosis, stenosis,
Carotid artery Hypoplasia Frequently asymptomatic
Carotid artery Dissection Neck pain, facial pain, headache, cranial nerve signs, Horner’s
Vertebral artery Atherosclerosis, dissection Neck pain, possible headache, TIA, CVA
Vertebral artery Hypoplasia Commonly silent
Abbreviations: TIA, transient ischemic attack; CVA, cerebrovascular accident
*Adapted from e International Framework for Examination of the Cervical Region for potential of vascular pathologies of the neck prior to orthopaedic
manual therapy intervention (International Federation of Orthopaedic Manual Physical erapists [IFOMPT] Framework, 2020).
thrombosis, aneurysm, dissection
Neck pain, facial pain, headache, cranial nerve signs, Horner’s
syndrome, TIA, CVA
syndrome, TIA, CVA
19
Academy of Orthopaedic Physical erapy, APTA.
16
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For personal use only. No other uses without permission.
Figure 1.
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*Reprinted with permission from omas LC, Rivert DA, Attia JR, Levi C.
© 2015, JOSPT®
Pain Presentations Associated with Vascular Pathologies of the Neck*
artery events, which are subtly different. Tables 6 and 7 review
signs and symptoms for both vertebrobasilar artery dissection
and internal carotid artery (ICA) dissection. In addition to acute
awareness of risk factors and careful attention to patient history,
some simple examination procedures
can also help to mitigate risks. Physical
therapists should routinely take blood
pressure for their patients according to
national and international guidelines.
Additionally, physical therapists should
utilize and become adept at palpation
and in particular auscultation of the ICA.
Note that to recognize abnormalities
during auscultation, regular and
frequent practice of auscultation on nonpathological ICAs should be performed.
One very notable change to the
2020 IFOMPT vascular pathologies of
the neck framework is the absence of
positional or provocative testing for the
purpose of “clearing” the cervical spine
46
for safe application of manual therapy
techniques. e validity of positional
testing, such as the vertebrobasilar artery
insufficiency (VBI) test is poor and
should not be used to provide a false
sense of confidence despite the presence
of multiple risk factors.
54
Additionally, positive findings during
positional testing or pre-manipulative holds can indeed produce
52,53
Table 6.
Signs of Vertebrobasilar Artery (VBA)
Dissection*
Signs, listed by frequency of
occurrence
Percentage of
presentation in
VBA dissection
Unsteadiness, ataxia 67
Dysphagia, dysarthria, aphasia 44
Lower limb weakness 41
Upper limb weakness 33
Nausea, vomiting 26
Facial palsy 22
Dizziness, loss of equilibrium 20
Loss of consciousness 15
*Adapted from e International Framework for Examination of
the Cervical Region for potential of vascular pathologies of the neck
prior to orthopaedic manual therapy intervention (International
Federation of Orthopaedic Manual Physical erapists [IFOMPT]
Framework, 2020).
19
Table 7.
Signs of Internal Carotid Artery (ICA)
Dissection*
Signs, listed by frequency of
occurrence
Percentage of
presentation in
ICA dissection
Ptosis 60-80
Upper limb weakness 65
Facial palsy 60
Lower limb weakness 50
Dysphagia, dysarthria, aphasia 45
Unsteadiness, ataxia 40
Nausea, vomiting 30
Loss of consciousness 20
*Adapted from e International Framework for Examination of
the Cervical Region for potential of vascular pathologies of the neck
prior to orthopaedic manual therapy intervention (International
Federation of Orthopaedic Manual Physical erapists [IFOMPT]
Framework, 2020).
19
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17
real neurological harm to patients. erefore, positional testing,
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such as sustained extension and/or rotation of the cervical spine
to assess for VBI is not recommended.
19,44,54–56
Practitioners
interested in exploring more about risk assessment and the
topic of vascular pathologies of the neck would do well to read
in full the 2020 IFOMPT vascular pathologies of the neck
framework (https://www.ifompt.org/Research+and+Resources/
OMPT+Frameworks+and+Clinical+Resources.html). e
framework explores additional topics such as provider and
instructor qualifications, clinical reasoning related to vascular
pathologies of the neck, and presents several case problems to
apply the framework and decision-making tools.
19
Ligamentous instability
Patients may present to physical therapy with various
levels of ligamentous instability of the cervical spine. is can
be in the form of congenital general hypermobility like what
might be encountered in someone with Ehlers-Danlos Type
III syndrome, or significant instability as a result of trauma.
Traditionally, physical therapists have used motion testing to
assess for alar and transverse ligament integrity, and segmental
motion assessment to test cervical spine mobility in general.
Symptoms consistent with ligamentous instability of the
craniovertebral junction include headaches, severe sub-occipital
or other muscle spasms, and fear and anxiety associated with
head motion.
constant, transient, or absent.
assessed using the Sharp-Purser test (Figure 2).
57
Neurological signs and symptoms may be
58
e transverse ligament can be
57–60
In this test,
the therapist first flexes the head to about 20-30° and assesses
for an onset of related symptoms such as bilateral numbness or
tingling in the arms. e therapist then applies a posteriorly
directed force to the cranium on a stabilized upper cervical
spine (C2) while the head and cervical spine are in this flexed
position. Because gravity along with the cervical flexion motion
would have theoretically caused the unstable cranium and C1 to
subluxate anteriorly on C2, causing the dens to move relatively
posteriorly and impacting the spinal cord, the posteriorly
directed force to the cranium should provide a resolution or
reduction in myelopathic symptoms presumably related to a
sliding motion of the cranium and C1 in the posterior direction
on the stabilized C2 vertebra. is resolving subluxation can
sometimes result in an audible clunk with the approximation
of the dens on the posterior aspect of the anterior ring of the
atlas, and this is considered a positive test. Clinicians should
note that a systematic review assessing the diagnostic validity
of the Sharp-Purser test found inconsistency in data regarding
60
diagnostic accuracy.
e authors of that review proposed that
the test should not be performed outside of a select population
60
of patients with rheumatoid arthritis.
e reason for their
position is that the sensitivity and negative likelihood ratio
values of the test resulted in minimal impact on post-test
hypotheses and so the screening value of the Sharp-Purser test
was not demonstrated. e positive likelihood ratio values were
also inconsistent but overall higher and so in cases of suspected
60
ligamentous insufficiency the test may be more valuable.
To assess the alar ligament, the therapist can palpate the
posterior aspect of the C2 spinous process as cranial (upper
cervical) side flexion is passively performed. Because C2
is anchored to the occiput in part with the alar ligament,
the spinous process of C2 should immediately move with
any cranial side flexion, in the direction opposite to the side
17
flexion.
test.
is is sometimes referred to as the C2 Spinous Kick
17
One should note that the alar ligament test probably also
assesses in part the tectorial membrane and cruciate ligament,
and integrity of the dens itself. e diagnostic accuracy of this
test is not strong enough to use as a stand-alone item in decision
making.
18,61–63
Figure 2.
Sharp-Purser Test
Malignancy and referred pain
Neck pain is the most common complaint associated with
cancers of the neck and head. In this instance, correlation to
other symptoms is warranted. Head and neck cancers most
often arise from squamous cell linings in the mouth and throat,
and so symptoms such as persistent sore throat, difficulty
swallowing, and even ringing in the ears are important to note.
Most head and neck cancers are diagnosed in men over age 50.
Because any spine bony tumor can be present as a primary or
secondary neoplasm, clinicians should screen for cancer in any
patient presenting with neck, shoulder, or radiating arm pain.
It is possible for pain from other internal organs to refer to
the periphery. In the case of neck pain, conditions associated with
lung and diaphragm pain can refer to the neck. Additionally,
the thymus gland can present as lower neck or upper back pain.
A less common location for the referral of cardiac symptoms is
also the anterior cervical spine in addition to the more common
areas of thorax, left extremity, and jaw pain.
18
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