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Screening for Psychosocial Factors
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Clinicians should be continually vigilant in screening
patients for yellow flags. Depression, anxiety, and other
psychosocial factors like self-efficacy can dramatically influence
prognostic trajectories. Providers should use patient interview
and specific measurement tools to identify these yellow flags.
e 2-item Patient Health Questionnaire (PHQ-2) has a high
sensitivity for screening to rule-out the presence of major
depression when negative, and when positive can serve as a tool
to indicate the need for further exploration. e PHQ-2 consists
of 2 questions: Over the last 2 weeks, how often have you had
little interest or pleasure in doing things? And, over the last 2
weeks, how often have you felt down, depressed, or hopeless?
Often clinicians will utilize positive answers to these questions
as opportunities to begin a deeper conversation with patients
about why they answered the way they did. In one notable
clinical encounter, a patient responded positively to feeling
down and depressed but negative to the second item. Upon
further discussion, the family pet had recently passed away. In
this case, the response from the patient was a completely normal
emotional response and no other evidence of a major depressive
episode was realized. However, if both questions are positive,
collaboration with a mental health care professional may prove
beneficial to the patient.
ere are a number of questionnaires that assist with
the assessment of psychological risk factors that may affect
outcomes. e Fear-Avoidance Beliefs Questionnaire (FABQ)
65
is a 16-item measure that speaks to patient fear and can indicate
when fear-avoidance may be a barrier to patient progress. ere
is a maximum score of 96 with higher scores indicating more
strongly held fear avoidance beliefs. e Pain Catastrophizing
Scale (PCS)
66
is a 13-item tool that measures a patient’s
experience with subscales on rumination, magnification, and
helplessness regarding pain with higher scores indicating a
greater extent of pain catastrophizing. Uniquely, an individual
does not have to be actively experiencing pain to complete
this questionnaire. Lastly, the Impact of Event Scale-Revised
(IES-R)
67
is a 22-item measure assessing the distress caused by
traumatic events with subscales on intrusion, avoidance, and
hyperarousal. e original IES was a 15-item measure but
excluded the hyperarousal items. A higher score on the IES-R,
and subscales, indicates a greater psychological impact from a
traumatic event. ese are just a few possible tools available to
assess potential psychological risk factors in patients and are not
exclusive to only those with neck pain.
Patient-reported Outcome Measures
Outcome tools are useful for identifying a patient’s
baseline status relative to pain, function, and disability and for
monitoring a change in a patient’s status throughout the course
of treatment. e most extensively used and researched outcome
measure for patients with neck pain is the NDI. e NDI also
has the nice benefit of being translated and validated into many
different languages. Psychometric properties of the NDI are
acceptable, and the minimum detectable change (MDC) score
is around 5/50 for uncomplicated neck pain and up to 10/50
for cervical radiculopathy. e reported clinically important
difference (CID) is inconsistent across different studies ranging
from 5/50 to 19/50.
68
Additional outcome tools that can be used for patients
with neck pain include the Patient-Specific Functional
Scale (PSFS), McGill Pain Questionnaire (MPQ), and the
68–70
Oswestry Disability Index.
While the Oswestry Disability
Index is most commonly associated with low back pain, its
content can be informative for patients with any central spine
pain. e PSFS is beneficial in many clinical settings as the
physical therapist and patient can incorporate individualized
measurements and ratings that span a variety of functional
71,72
and participatory restrictions succinctly and efficiently.
e
MPQ exists in short and long form versions. e short form
version can function as an efficient baseline pain assessment that
can indicate the need for further pain assessment tools such as
queries for neuropathic pain, etc. In addition, the MPQ can
serve as an alternative to a simple numeric pain rating scale for
tracking patient progress.
History and Interview
Taking a thorough patient history is the first critical step to
effective patient management. Many clinical diagnoses, along
with relevant risk factors, can be accurately identified through
good history taking, which will help the clinician with the
clinical reasoning processes that are important for each patient.
History taking should be a primarily patient-led interview
focusing on open-ended questions and can use any number of
good communication strategies. In the author’s experience, it
is often helpful for clinicians to start a history by allowing the
patient to speak for 90 seconds uninterrupted. is may feel like
an exceedingly long time for clinicians who are not accustomed
to this technique. In fact, primary care providers typically
73
interrupt patients after as little as 12 seconds.
It is suggested
that allowing the patient to speak freely at the beginning of an
interview can result in improved overall efficiency throughout
the entire patient encounter. While detailed and comprehensive
information on the history taking process is outside the scope of
this monograph on the cervical spine, a brief overview of critical
points for this region will be reviewed.
History of present illness
Determining the events leading to the present symptoms or
functional limitation complaints is the first step in distilling all
the patient information into a set of cogent, testable hypotheses.
In the cervical region, it is particularly important to determine
whether or not the onset was traumatic or non-traumatic.
Traumatic onsets should trigger the clinician to consider if the
patient meets requirements for fracture screening using the
Canadian Cervical Spine rules or Nexus Criteria. A traumatic
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19
onset can also impact risk assessment for related conditions like
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vascular pathologies of the neck or ligamentous insufficiency.
Based on a particular patient’s comorbidities, even mild trauma
can be significant in the cervical spine. For example, a patient
with low bone mineral density can experience a fracture from
even a small fall. Likewise, patients with rheumatoid arthritis
could present with ligamentous laxity at the craniovertebral
junction and could have significant injuries from relatively mild
61
trauma.
Symptom location
Determining the location of symptoms refers to not only
listening to where the patient directs the provider to, but also
paying attention to how patients report symptoms in related
regions. Often, patients will fill out a symptom diagram prior
74–76
to meeting the clinician.
e clinician should then confirm,
using touch if possible, the locations of the symptoms indicated
on the diagram. Additionally, paying careful attention to how a
patient’s gestures to or around their symptom location can help
the provider understand the patient’s experience. For example, a
patient may point to a specific location of pinpoint tenderness
with a single fingertip, or alternatively use a broad sweeping
gesture to indicate more diffuse, widespread, or traveling pain.
In the cervical spine, pain can be referred from various
structures, occasionally taking the form of headaches. When
patients present with complaints of headache, follow-up
questions about the type, nature, location, and frequency of
headache are indicated. Headaches present in the forehead
region can indicate myofascial dysfunction in the craniooccipital region or sinusitis. Headaches in the occipital
region can be caused by a variety of causes such as eye strain,
hypertension, or craniomandibular dysfunction. Cervicogenic
headaches often present with a classic ram’s horn presentation.
Symptom location can also inform about the presence of
referred versus radicular pain. Referred pain can cross several
dermatomes and tends to occur in predictable locations.
For example, the upper cervical segments tend to refer pain
upward to the cranium, while the lower cervical segments
refer to the posterior shoulder girdle and less so down the arm.
Contrastingly, radicular pain will follow specific spinal nerve
root distributions and can extend distally into the hand and
digits.
It can also be helpful for clinicians to distinguish between
sensations of numbness and tingling and/or paresthesias
with confirmed neurological deficits like reduced 2-point
discrimination or muscle weakness, for example. Referred
symptoms can sometimes result in paresthesias but only
radicular symptoms will produce positive neurological findings.
A patient with referred pain from the neck may indicate
a tingling sensation in their shoulder or upper arm, but
neurological testing can be negative. A patient with radicular
symptoms, may in contrast, present with weakness in the C5
myotome in addition to experiencing paresthesias.
Likewise, progression of neurological findings can inform
the clinician about the severity of the condition. It is most
common for radiculopathy to present with minor sensory
changes. In more severe cases, mild or severe weakness can also
be present as can changes in deep tendon reflexes. Prognosis and
management trajectories can vary widely depending on severity.
For example, a patient with radiculopathy with mild sensory
changes can be managed non-surgically while a patient with
severe and progressing muscle weakness will need a surgical
referral.
Behavior of symptoms
Understanding how severe symptoms are and how
symptoms may change or be impacted by a patient’s functional
requirements can help the provider appreciate how the pain
is affecting the patient overall. A patient’s pain may change
significantly over a 24-hour period. Perhaps work postures
make the pain worse. Perhaps the pain is only present at night.
Each of these scenarios might dictate a different line of inquiry
for the clinician. Understanding if the problem is constant
or intermittent, improving or worsening, or stable, can all
impact how the provider understands the patient’s experience.
Additionally, specific lines of questions should be incorporated
that seek to understand those factors that aggravate the
symptoms, and those that provide relief.
When asking about aggravating and easing factors, things
like pain level, function, and irritability should be considered.
When exploring symptom behaviors, clinicians should attempt
to link aggravating and easing factors. For example, it might be
more helpful to determine how long and what activity eases a
patient’s pain that was aggravated by driving than just simply
knowing that ROM exercises and lying down ease the pain.
Time components to this consideration are important and
can be the basis for starting to determine the effects of various
intervention strategies (Table 8).
Determining the Nature of the Problem
When possible, seeking to understand the cause of a patient’s
pain is important. However, for many types of musculoskeletal
pain this is not possible, and the cervical spine is no exception
to this, with many patients presenting with non-specific neck
pain. Because a patient’s pain experience is multi-factorial,
8
recent guidelines
have gone so far as to direct clinicians away
from attempting to determine pathoanatomic causes for neck
pain. is has subsequent impact on the use of imaging studies
for understanding a patient’s condition. Walton and Elliott
77
have proposed the use of a radar plot to help understand the
multifaceted nature of a patient’s pain experience (Figure 3).
77
Walton and Elliott
describe the purpose of their radar
plot model as a way to improve the development of pattern
recognition skills. e radar plots can allow clinicians to make
judgements about the relative contribution of various aspects
of a patient presentation without requiring a label or diagnosis,
20
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Table 8.
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Examples of Symptom Irritability Assessment
Irritability Aggravating Factor Easing Factor
High Driving 5 minutes increased pain from
0/10 to 8/10 on NPRS
30 minutes rest
returns pain to 0/10
on NPRS
Moderate Driving 30 minutes increased pain from
0/10 to 5/10 on NPRS
30 minutes rest
returns pain to
0/10 NPRS
Low Driving 30 minutes increased pain from
0/10 to 1/10 on NPRS
Looking over shoulder increased pain
from 0/10 to 2/10 on NPRS
5-minute rest returns pain to
0/10 on NPRS
Coming out of position
returns pain to 0/10
on NPRS
Abbreviation: NPRS, Numeric Pain Rating Scale
thus providing an important contextual layer to how a clinician
understands the patient in front of them. is tool is meant to
be used after a patient has passed through screening for red flags
and is considered appropriate for care. e radar plot provides a
visual tool to explore the patient’s pain experience. e domains
in the radar plot are as follows:
77
Nociceptive (physiologic) input: is refers to pain
produced primarily by nociceptive afferents. It could be thought
of as acute mechanical or inflammatory pain.
Figure 3.
Illustration by Kinstler Design.
Radar Plot Tool
Impact on Examination
and Intervention
Low vigor examination,
be cautious of reproducing
symptoms
Normal vigor, cautious of
reproducing symptoms
Normal to high vigor, little
chance of reproducing
symptoms
Peripheral neuropathic: Although this category sounds
similar to a diagnostic label, it refers to neuropathic pain, or pain
derived from disease of the somatosensory system as described
by the International Association for the Study of Pain.
78
Central nociplastic: is describes pain that is not the
result of peripheral input and could be considered similar to the
term “central sensitization.”
Emotional/affective dysregulation or pathology: is
would be those conditions described in the American Psychiatric
Associations Diagnostics and Statistical Manual–V (DSM-V)
79
and includes mood disorders, anxiety, and depression.
Maladaptive cognitions: is category includes illogical or
incorrect beliefs related to pain, such as pain catastrophizing, or
altered beliefs as to the nature of or solution to the problem. e
beliefs or states of mind in this category do not have diagnostic
labels in the DSM-V.
Socioenvironmental context: is is a broad category
that describes various contextual factors such as access to
care, cultural elements, ethnicity, willingness to report, socioeconomic considerations, and access to care.
Sensorimotor dysintegration: is describes altered input
or disagreement between 2 different sensory inputs, such as
disagreement between the visual and vestibular systems as to
the position of the head for example.
Two examples are provided to help elucidate the use of the
radar plot for pattern recognition. Clinicians are not rating the
items in the plots against any standard, but in terms of their
own perception of the extent of contribution of each of the
listed categories. It is helpful that the categories defined in the
radar plot generally align with various interventions strategies
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21
on which to take action, though some of these actions might be
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outside the scope of physical therapist practice.
Example 1: A 22-year-old heiress of a major hotel chain
presents to a physical therapist after twisting her ankle running
on the beach as a thunderstorm approached. e patient did
not require radiographs and presents with mild loss of motion,
mild pain, minimal edema, and no ligamentous laxity consistent
with a Grade I lateral ankle sprain. e patient has a medical
history significant for anxiety and depression and one previous
ankle sprain several years earlier. e radar plot interpretation of
this patient is presented in Figure 4.
Example 1 Interpretation: is is an acute injury and from
the information given, not complicated by central processes
or neuropathic pain. We can assume access to care is not a
problem for this wealthy individual. e pain experience is
likely confined to nociceptive input from the local tissue around
the lateral ankle. Her history of anxiety and depression could
influence her experience in care and should be noted.
Example 2: A 47-year-old landscape worker presents to
physical therapy with neck pain following a day of shoveling
gravel for a backyard renovation. e patient reports they have
experienced some amount of neck and back pain constantly for
the past 4 years, and that bedrest always helps them feel better.
e patient is fearful of losing their employment position if
they have to be in bed for a prolonged period of time, although
feels unable to complete the tasks their job requires at this point
in time. Pain is described as 10/10 on a numeric pain scale.
e patient presents with reduced sensory and motor function
consistent with impairment of the C7 nerve root. e patient’s
medical history is significant for hypertension, Type II Diabetes
Mellitus, and asthma for which they are taking medication
regularly. e author’s radar plot interpretation of this patient is
presented in Figure 5.
Figure 4.
Radar Plot Example 1
Figure 5.
Illustration by Kinstler Design.
Radar Plot Example 2
Example 2 Interpretation: is landscape worker presents
with a more complex situation than the previous example.
It seems persistent pain has been a problem for some years,
although neurologic findings hint at a radiculopathy, therefore
both central nociplastic changes and neuropathic pain are
strong contributors. e reliance on bedrest and complications
with the employment situation, as well as uncertain access to
care, add contributing factors to socioeconomic factors and
maladaptive cognition. Because this patient’s pain complaint is
more severe, the extent of contributing factors is shaped quite
differently than in example 1.
Together, these 2 examples serve as illustrations for how
a simple and complex patient presentation can be appreciated
using the radar plots. Over time, an inherent understanding, or
pattern recognition, develops and clinicians can obtain a more
nuanced view of the nature of a patient’s problem than simply
relying on a diagnostic label to communicate information
beyond the scope of that label. e authors recommend
frequent practice and calibration with other professionals as
the radar plot models are considered for inclusion in practice.
Additionally, these models can serve as helpful additions to
reflection forms used by students from entry-level through
fellowship education.
Illustration by Kinstler Design.
Tests and Measures
Observation
Observation of patient posture and the relative alignment
of their head and neck is a common starting point when
conducting a physical examination. e extent of forward
head posture and protraction of the scapulae should be noted.
Importantly, patients can present with guarding or in postures
due to pain or trauma, and this can begin to inform the physical
therapist about severity and irritability of the condition.
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Although posture has not shown strong associations with pain
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or function, instances of extreme postural abnormality should
be noted. For example, a patient may present to the clinic with
one shoulder held in an extreme elevated position after a motor
vehicle collision. e clinician can take clues from this about
the level of irritability and possible involvement of the upper
trapezius muscle.
Patients with chronic degenerative conditions, like spinal
stenosis or cervical myelopathy may have adopted marked
abnormal postures over time. Careful movement testing can
help determine if these postures are related to the patient’s
pain and if addressing the postural abnormality can provide
improvement for the patient. Posture may also be considered
relative to the functional tasks a patient performs. For example,
a patient with complaints of pain at work could be evaluated in
a seated position at their workstation for a valid assessment of
the posture that may be problematic for that patient.
Active movement assessment
Assessing active ROM is the typical start for many
assessments and that is not different for the cervical spine. Motion
assessment can provide critical information broadly about
irritability, fear of motion, and how vigorous an examination
should be conducted. Patterns of motion limitations, or
correlations between motion limitation and symptoms, can all
inform clinical reasoning. Changes in motion, and particularly
changes in motion that reproduces pain, can serve as short-term
guides for treatment progression.
Neck ROM measurements can be conducted with both a
goniometer and inclinometer and can be an important reference
point for demonstrating and tracking treatment progression
as well as assisting in clinical reasoning. Cervical ROM is an
important physical examination marker in particular for ruling
in or out patients who present with neck pain with mobility
deficits and cervicogenic headaches.
80
In addition to assessing for cervical motion, clinicians
should screen for thoracic spine mobility. While the exact
amount of motion availability (in degrees) is not required,
general assessments categorizing motion as painful or not
painful and normal, hypermobile, or hypomobile can assist
with clinical reasoning and directing treatment. Because the
thoracic spine shares so many anatomical relationships with
the cervical spine, it is common to find impairments in both
regions. When screening for thoracic spine motion, the patient
should be positioned so that their feet are flat on the floor and
the head is in an upright position. Likewise, when assessing
cervical ROM, the physical therapist should ensure an upright
thoracic position to standardize the assessment. Following is a
description of assessing cervical and thoracic ROM.
Cervical Flexion, Extension, Side Flexion: e patient is
seated with feet flat on the floor and thoracic spine in an upright,
yet comfortable position. e patient is cued to first move their
head through the range. Cuing is best with patient friendly
language like: “look up,” “look down,” and “bring your ear to
your shoulder.” is cuing can be adjusted based on patient
irritability and our willingness to provoke symptoms. For
example, in assessing cervical flexion for a patient with higher
irritability, they might be cued to “look down as far as you can
comfortably” with the goal to minimize symptom provocation,
and for a patient with lower irritability the cuing can be to “look
down as far as you can.” An inclinometer can be used to quantify
the available motion. e physical therapist should also note the
quality and response to motion. Overpressure can be applied to
further elucidate components of motion quality and irritability.
Any substitutions of motion and specific regions of limitation
should be noted and further confirmed with segmental motion
testing and or flexibility assessment.
Cervical Rotation: Again, the patient is seated with feet flat
on the floor and thoracic spine in an upright, yet comfortable
position, then cued to look over their shoulder. e physical
therapist can use a traditional goniometer place at the center
of rotation on the top of the head to assess for this motion.
To accomplish this vantage point the therapist may need a step
stool while the patient is sitting in a shorter chair to look down
over the patient and goniometer. During this assessment, the
relative contributions of cervical rotation from the upper versus
lower cervical spine regions should be kept in mind.
During cervical ROM assessment the patient’s eyes should
be open and the examiner should observe the patient’s eyes and
face for any signs of cranial nerve impairment during testing.
Figure 6A-C demonstrates cervical ROM assessment with
overpressure for flexion, extension, and rotation, respectively.
oracic Rotation: Exact measurement with an inclinometer
is not needed for this assessment. e patient should be seated
with their feet flat on the floor and head in a neutral position.
e physical therapist should have the patient cross their arms
over their chest. e physical therapist then provides cues for
the patient to twist to one side while keeping their nose pointed
at their elbows. is reduces the potential for cervical rotation.
While the patient is rotating, the therapist positions their body to
block lower extremity motion with their leg against the patient’s
ipsilateral knee. e physical therapist can provide overpressure
through the shoulder girdle from this position. Motion quality
and quantity and pain response should be noted.
is is a gross motion assessment that also incorporates
lumbar rotation. If the patient experiences symptoms with this
motion, the therapist can localize the ROM assessment to the
thoracic spine by having the patient heel-sit with their elbows on
the ground to decrease lumbar motion. e bubble inclinometer
is centered over the C7-T1 interspinous space, perpendicular to
the spine. e patient is then cued to bring their hand to their
ipsilateral shoulder (with the arm to the side of their body) and
81
twist their shoulder to the ceiling.
If the patient is unable to
achieve the position described, the therapist can further assess
mobility with a segmental mobility assessment. Motion quality
and quantity and pain response should be noted.
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23
Figure 6.
A B
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Active Range of Motion Assessment with Overpressure
A
B
A, Cervical flexion. B, Cervical extension. C, Cervical rotation.
Of course, passive cervical ROM can be performed in
supine allowing the patient to better relax for movement to
be assessed with less soft tissue tension and cervicoscapular
musculature influence. As such, greater motion might be
available, or information can be discerned about the nature of
motion limitations, especially for patients with acute, severe,
or high-level of irritability when performed in this unloaded
position.
Likewise, patterns in motion loss or particular directions
of motion limitations can be informative. Traditionally, loss of
combined extension and rotation movements might hint to
degenerative changes at a facet joint. Cervical radiculopathy is
associated with loss of rotation motion from the lower cervical
spine. Loss of motion in all directions and with an empty end-feel
can indicate a highly irritable condition, perhaps as one could
present following a motor vehicle collision. Motion loss in the
cervical spine that also is associated with loss of shoulder girdle
movement can indicate either a problem at both the shoulder
and cervical spine, or direct clinicians to carefully evaluate the
flexibility of cervical musculature that have attachments on the
scapula or clavicle.
Segmental motion assessment
A useful examination technique employed by many
physical therapists is segmental mobility assessment. e
purpose of segmental mobility testing is to assess the amount
of motion available and symptom modification at individual
spinal segments in relation to the segment above or below the
reference segment. is motion is also referred to as accessory
hypomobile (decreased), normal, or hypermobile (excessive).
C
When assessing the cervical spine below C2, the patient
can be prone or supine. For the prone position, the patient’s
head and neck are positioned in neutral rotation which usually
requires the face-plate of a plinth to be angled down slightly.
e plinth height should be adjusted so that the physical
therapist is in a comfortable position with the elbows straight
but not fully extended. e physical therapist stands at the end
of the table that provides easy access to the head and neck of
the patient, approximates the dorsal aspect of the thumbs, and
contacts the spinous process of the intended cervical vertebrae
(Figure 7A). For therapists with thumbs that hyperextend,
placing the dorsum of the thumbs together can assist in
providing support for their own joints. e physical therapist
will use their remaining fingers to gently bring the lateral
musculature posteriorly, creating some slack on the surrounding
soft tissues, for the patient’s comfort. With elbows stable, in
a relaxed extended position, the physical therapist uses their
body to apply a gradual (beginning gentle, progressing to firm),
posterior-to-anterior (PA) pressure on the spinous process to
determine whether segmental mobility is hypomobile, normal,
or hypermobile as well as if the segment is painful or not painful.
A unilateral PA assessment is performed in the same position
and manner but with the therapist’s thumbs contacting only 1
articular pillar. is unilateral PA is used to focus force at one
side of the spine at a time. When performing these, the clinician
should modulate force to not overpower the small cervical
joints. Additionally, this technique provides an opportunity to
explore various angles of force and different head positions to
gather the maximum amount of information about any motion
limitations (Figure 7B).
Physical therapists generally feel that central PAs are
somewhat accurate or very accurate for estimating the quantity
24
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Figure 7.
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Segmental Mobility Assessment
A
B
A, Central posterior-to-anterior mobility assessment
and graded mobilization. B, Unilateral posterior-to-
anterior mobility assessment and graded mobilization.
of movement present in the cervical segments.82 Posteriorto-anterior pressures performed on either side of the spinous
process, as described above, commonly called unilateral PAs,
are intended to assess the mobility of the articular structures of
a particular side (left versus right) of a segment. e physical
therapist should keep in mind that applying a PA force to 1
segment will create movement of the entire cervical spine and
thus is not an isolated assessment. Forces used for PAs whether
central or unilateral have high inter-therapist variability, but
the intra-therapist variability is low, irrespective of the grade
being applied (I-IV). e diagnostic accuracy during segmental
mobility testing associated with report of neck pain was:
sensitivity = 0.82, negative likelihood ratio = 0.23, specificity =
0.79, and positive likelihood ratio = 3.9.
7
Judgment on mobility is based on the examiner’s
expectation of what normal is at that segment compared to the
other cervical segments of that patient. Following the history
and ROM assessment, the therapist should have a preliminary
idea about the region (upper, middle, or lower cervical spine)
of likely involvement. It is best to begin testing segmental
mobility away from the suspected area of concern so the patient
and therapist better understand what the unaffected regions
feel like for comparison. Additionally, previous experience of
segmental mobility assessment will help the physical therapist
make judgments regarding the mobility of the segment. Prior
to the segmental mobility examination, the physical therapist
should obtain a baseline of the patient’s status. en, during
and after the segmental mobility examination, the relation
between the PA pressures and the patient’s symptoms should be
reassessed. Symptom reproduction with PA pressures increases
the likelihood that the segment is related to the patient’s
reported pain-related limitations.
An alternate method for assessing segmental mobility of
the neck is with the patient supine with a lateral glide (Figure
8). With this technique, the physical therapist will locate the
spinous process of the desired segment to assess and then place
their index and middle fingers of each hand contacting the
articular pillar on both sides of a segment’s spinous process. At
this point, the examiner uses their right hand to apply a passive
right to left movement followed by using the left hand to apply
a passive left to right movement. e examiner assesses the
quantity of motion as hypermobile, hypomobile, or normal,
whether the movement is painful or not painful, and the quality
of the end-feel at each segment and with each direction. is
segmental assessment can be modified to bias an extension or
flexion movement by first positioning that segment into slight
flexion or extension prior to performing the lateral glide.
Muscle length assessment for cervical related muscles
Tightness of the cervical musculature can affect a patient’s
movement and contribute to symptoms. erefore, assessing
the length of these and adjacent muscles will assist the physical
therapist identify impairments and subsequently plan the
Figure 8.
Cervical Lateral Glide
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25
treatment program. All muscle length assessments should be
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done bilaterally.
To assess the pectoralis minor muscle, the patient is
positioned supine with their arms by their side with elbows
extended. e distance from the posterior angle of the acromion
to the table is assessed. A positive finding would be associated
with an increased distance on the affected side as compared
to the unaffected side. Because there is no normative distance
for this, the assessment should be considered in context to the
patient’s global presentation. It is important to differentiate
among structures that could also affect this passive positioning
including the biceps brachii (shortened by elbow flexion) and
coracobrachialis (shortened by slight shoulder flexion), in
addition to the pectoralis minor. If the posterior angle of the
acromion to the table distance does not change with elbow
flexion and slight shoulder flexion, then the pectoralis minor
muscle is the likely contributor.
To assess the pectoralis major muscle, the patient is lying
supine with both knees flexed with their low back flat to the
plinth. For the upper (clavicular) fibers of the pectoralis major,
the arm is horizontally abducted with the palm up until a
stretch is felt. e lower (sternal) fibers are assessed with the
patient in the same position with the arms in 135° of abduction.
If the patient is able to lay their arm flat on the table, then
the muscle length is normal. is should be compared to the
contralateral side and documented with distance measurement
from the lateral epicondyle to the table.
To assess the anterior and middle scalene and SCM
muscles, the patient is supine with the head and neck on the
edge of the plinth (Figure 9). e occiput is supported by one
of the physical therapist’s hands and secured by the physical
therapist’s other hand on the forehead. e patient can hold the
side of the plinth for scapular stabilization of the tested side.
e therapist then retracts the cervical spine, paying attention
to not simply extend the neck, while also bringing the upper
cervical spine in flexion. Finally, the cervical spine is taken into
contralateral side flexion and ipsilateral rotation until a stretch
is felt in the area of the scalene and SCM muscles.
To assess the levator scapulae muscle, the patient is supine
on the plinth (Figure 10). e therapist stabilizes the superior
angle of the scapula of the tested side with the ipsilateral hand.
e therapist then depresses the scapula from this position
using a stabilizing hand sinking into the plinth to help maintain
the depression. e therapist’s other hand cradles the occiput
and flexes the cervical spine with contralateral side flexion and
rotation (nose towards opposite armpit). Assess the ROM and
symptoms at end-range compared to the other side.
To assess the upper trapezius muscle, the patient is supine
on the plinth (Figure 11). e therapist stabilizes the lateral
spine of the scapula with the ipsilateral hand. e therapist then
depresses and downwardly rotate the scapula from this position
Figure 10.
Levator Scapulae Muscle Length
Assessment and Stretch
Figure 9.
Anterior and Middle Scalene and
Sternocleidomastoid Muscle Length Assessment
and Stretch
26
Figure 11.
Right Upper Trapezius Muscle Length
Assessment and Stretch
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using an inferiorly directed force. e therapist’s other hand
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cradles the occiput and flex the cervical spine with contralateral
side flexion and ipsilateral rotation (ear towards opposite
armpit). Take note of the resting position of the scapula prior
to assessing the length of the upper trapezius. If the patient
presents with a depressed or downwardly rotated scapula, they
may develop symptom reproduction during the test. is is
a false positive finding. e symptom reproduction is caused
by stretching an already elongated muscle. Stretching the
upper trapezius in this situation is not the treatment of choice.
Normalizing scapular position should be the primary focus for
this patient presentation.
Decision-making Algorithm for
Patients with Neck Pain
Blanpied et al
8
produced a CPG to assist clinicians in
managing patients with neck pain. Subsequent to this guideline,
a decision-making algorithm or flowsheet was developed to
provide a concise, user-friendly summary of the document.
83
e authors of the CPG advocate for classification of patients
with neck pain into 4 broad categories based on history and
examination findings. Like for many body regions, particularly
the lumbar spine,
84
grouping patients into categories can help
providers make decisions in the face of uncertainty or when
specific pathoanatomical structures are impossible to identify.
For patients with neck pain, the categories of classification are:
neck pain with mobility deficits, neck pain with movement
coordination impairments (which includes patients with
WAD), neck pain with headache, and neck pain with radiating
pain. Inclusion of a patient in a category, based on common
symptoms and clinical findings, then directs interventions
based on the best evidence for each classification. Figure 12
details the initial part of this classification algorithm. One
critical aspect to utilizing classification algorithms such as
this one is the appreciation that most individuals will not fit
exclusively into one category and patients might not be perfect
fits for any category. It is up to the clinician to make decisions
and prioritizations on patient care by translating the findings of
the guidelines to their patient’s unique goals and circumstances.
Assessing Neck Pain with Mobility Deficits
Patients presenting with motion limitations as a primary
finding can be easily identified and grouped into a diagnostic
category that prioritizes treatment to those limitations.
As the name implies, the neck pain with mobility deficits
classification denotes those individuals with limited mobility of
the cervicothoracic spine. While symptoms may be broad and
variable in this group of patients, the primary finding is limited
mobility with the absence of any radiating pain or trauma.
Patients in this category likely have central or unilateral cervical
pain that may or may not refer to the shoulder girdle and upper
quarter. Notably, radiating pain into the distal upper extremity
would exclude someone from this category. Symptoms are
typically impacted by cervical or segmental motions testing.
Careful exploration of all cervical active and passive
physiologic motions as well as mobility of the thoracic spine
is indicated. To this end, clinicians will find that patients
in this category tend to present with few positive special
tests and a negative neurological screen. e limitations in
motion are primarily joint and capsular limitations, although
individuals with general stiffness and lack of flexibility in the
cervicothoracic musculature would also fit into this category. It
is not uncommon for these patients to have segmental mobility
deficits at several levels which may or may not be painful.
Patients with osteoarthritic changes of the cervical spine
without evidence of radiating pain would also likely fall within
this category. erefore, older patients without radiating pain
and a non-traumatic onset of symptoms will often fit into this
classification.
Occasionally, patients in this category will also present
with diminished strength of the muscles that support neck and
scapular mobility and stability as previously described. is is
more common in those patients with subacute and chronic
symptoms.
Several specific examination items can be used to help
identify and track the progress of impairments for patients
who have neck pain with mobility deficits. First is the cervical
rotation lateral flexion (CRLF) test (Figure 13) which can be
used to assess first rib mobility and cervicothoacic junction
mobility. e patient is seated towards the front of the plinth
with their feet flat on the ground with the therapist kneeling
behind the patient to control the trunk with the therapist’s hip.
e therapist places their hand on the first rib that is being
assessed to help stabilize the trunk. e other hand grasps the
patient’s cranium and passively provides contralateral rotation.
While maintaining full rotation the therapist then laterally
flexes the patient’s head noting the ROM. A positive test is a
notable discrepancy (limitation) in lateral flexion ROM with
a hard end-feel. Hypomobility, symptom change, or change
in a related symptom area could also be considered significant
findings while performing this test.
Clinically, the CRLF test may also identify patients who,
in addition to limited first rib mobility, have general motion
limitations in and around the cervicothoracic junction.
Correlation with segmental assessment and muscle flexibility
can be both helpful diagnostically and serve as an outcome
assessment to track response to interventions. For example, if a
patient presents with a positive CRLF test and limited flexibility
of the levator scapulae muscle, it is not uncommon for both
the CRLF and muscle flexibility to improve after interventions
directed specifically at the first rib, even though the levator
scapulae muscle has no connection to the first rib. erefore,
while biomechanical assessments describe the CRLF as a first
rib test, the clinical reality may be that the test can identify more
diffuse hypomobility in the region. e CRLF is a convenient
test to include while the patient is already in a seated position
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27
Figure 12.
Neck Pain: Clinical Practice Guidelines Revision 2017
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Classification Algorithm for Patients with Neck Pain Based on the Academy of Orthopaedic Physical erapy
Clinical Practice Guidelines
83
Evaluation/Intervention Component 1: medical screening
Appropriate for physical therapy
evaluation and intervention
versus versus
Appropriate for physical therapy
evaluation and intervention along
with consultation with another
health care provider
Evaluation/Intervention Component 2: classify condition through evaluation of clinical
findings suggestive of musculoskeletal impairments of body functioning (ICF) and the
associated tissue pathology/disease (ICD)
Neck Pain With
Mobility Deficits
Common symptoms
• Central and/or unilateral neck
pain
• Limitation in neck motion that
consistently reproduces
symptoms
• Associated (referred) shoulder
girdle or upper extremity pain
may be present
Expected exam findings
• Limited cervical ROM
• Neck pain reproduced at end
ranges of active and passive
motions
• Restricted cervical and thoracic
segmental mobility
• Intersegmental mobility testing
reveals characteristic restriction
• Neck and referred pain
reproduced with provocation of
the involved cervical or upper
thoracic segments or cervical
musculature
• Deficits in cervicoscapulothoracic strength and motor control
may be present in individuals
with subacute or chronic neck
pain
Neck Pain With Movement
Coordination Impairments (WAD)
Common symptoms
• Mechanism of onset linked to
trauma or whiplash
• Associated (referred) shoulder
girdle or upper extremity pain
• Associated varied nonspecific
concussive signs and symptoms
• Dizziness/nausea
• Headache, concentration, or
memory diculties; confusion;
hypersensitivity to mechanical,
thermal, acoustic, odor, or light
stimuli; heightened aective
distress
Expected exam findings
• Positive cranial cervical flexion
test
• Positive neck flexor muscle
endurance test
• Positive pressure algometry
• Strength and endurance deficits
of the neck muscles
• Neck pain with mid-range
motion that worsens with
end-range positions
• Point tenderness may include
myofascial trigger points
• Sensorimotor impairment may
include altered muscle
activation patterns, proprioceptive deficit, postural balance or
control
• Neck and referred pain
reproduced by provocation of
the involved cervical segments
Neck Pain With Headache
(Cervicogenic)*
Common symptoms*
• Noncontinuous, unilateral neck
pain and associated (referred)
headache
• Headache is precipitated or
aggravated by neck movements
or sustained positions/postures
Expected exam findings
• Positive cervical flexionrotation test
• Headache reproduced with
provocation of the involved
upper cervical segments
• Limited cervical ROM
• Restricted upper cervical
segmental mobility
• Strength, endurance, and
coordination deficits of the neck
muscles
Not appropriate for physical therapy
evaluation and intervention
Consultation with appropriate health
care provider
Neck Pain With Radiating Pain
(Radicular)
Common symptoms
• Neck pain with radiating (narrow
band of lancinating) pain in the
involved extremity
• Upper extremity dermatomal
paresthesia or numbness, and
myotomal muscle weakness
Expected exam findings
• Neck and neck-related radiating
pain reproduced or relieved with
radiculopathy testing: positive
test cluster includes upper-limb
nerve mobility, Spurling’s test,
cervical distraction, cervical
ROM
• May have upper extremity
sensory, strength, or reflex
deficits associated with the
involved nerve roots
FIGURE. Proposed model for examination, diagnosis, and treatment planning for patients with neck pain. *Clinicians are encouraged to refer to the International Classification
of Headache Disorders
Health and Care Excellence
Figure continues on page A23.
83
for a more inclusive list of headache types/classifications (https://www.ichd-3.org/how-to-use-the-classification/), and to The National Institute for
149
for signs, symptoms, and conditions that should be considered in patients who present with a headache in addition to neck pain.
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28
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For personal use only. No other uses without permission.
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