THE CERVICAL SPINE

 


THE CERVICAL SPINE

Following on from the subjective assessment, the physiotherapist should highlight the main findings and formulate a hypothesis regarding the clinical diagnosis. The SIN factors will determine the vigour of the examination. The physiotherapist will attempt to find the patient’s comparable sign by means of movement or palpation.


Posture

Note the symmetry of the head on the neck, and the neck relative to the thorax. The chin should be at 90 degrees to the anterior aspect of the neck. There should be no obvious horizontal skin creases posteriorly. A plumbline from the tragus of the ear should fall behind the clavicle. Assess the cervical lordosis. A decreased lordosis predisposes the vertebral bodies and discs to bear more weight. An increased lordosis increases the compressive loads on the zygapophyseal (facet) joints and posterior elements. Observe for muscle hypertrophy, hypotrophy, spasm, tightness or general asymmetry. An acute wry neck (torticollis) presents as a combination of flexion and rotation or side flexion away from the painful side. Patients with chronic pathology often have a poking chin posture which consists of excessive upper and middle cervical extension and lower cervical/cervicothoracic flexion. This results from a weakness of the deep cervical flexors and overactivity of sternocleido­mastoid and levator scapulae muscles . Note that cervical posture is influenced by lumbar posture and, hence, the poking chin posture is exaggerated by lumbar and thoracic flexion. Cervical and shoulder posture should, therefore, be viewed in both the sitting and standing postures. The shoulders should, ideally, be level, but this is often not the case because of handedness. For example, in a right­handed person the right shoulder is often held slightly lower than the left.


Movements

It is important to not only assess the range of movement occurring in the cervical region but also the quality of that movement. Note, in particular, the motion segments where the movement is occurring. Hinging may be observed, which indicates areas of hypermobility or instability. Conversely, areas of hypomobility or stiffness are observed as areas of plane or straight lines.

 

Active movements

Flexion The movement should be performed to either the patient’s pain or the limit of movement. During flexion the cervicallordosis should be obliterated and the spine appears to be flexed or neutral. The spinous process of C7 should be the most prominent – C6 and T1 less so. The chin should approximate the chest. Common faulty patterns are the upper cervical spine remaining in extension or chin poke. Loss of range, areas of give and restriction should be noted, as well as the pain response, muscle spasm and crepitus.

Extension

 The entire cervical spine should extend, and the face should be almost parallel to the ceiling. A vertical line should be observed from the chin to sternum. Common faulty movement patterns include a loss of lower cervical extension and the head does not move posteriorly to the shoulders. Furthermore, excessive hyperextension of the upper and mid cervical spine may occur earlier on in the movement and the chin pokes forward.

Side flexion

Often this movement is the most restricted in degenerative spinal pathologies. Tightness in the contralateral sternocleidomastoid and trapezius may be observed. Common faulty patterns include coupling with rotation owing to tightness in anterior flexor musculature. Observe range, pain response and areas of give or restriction. Compare the sides for symmetry.

Right and left rotation

Observe the range of movement available and the patient’s pain response, muscle spasm and crepitus. Common faulty patterns include coupled movements with side flexion and the eyes not moving in a purely horizontal plane. Compare the right and the left sides.

Overpressures repeated and combined movements

If the plane movements are full range and pain­free, then overpressure may be applied. At the end of the available range the physiotherapist may apply a small oscillatory movement to feel the quality and end­feel of the movement, and the range of further movement. The pain response is also noted. Combined movements may be examined in an attempt to reproduce the patient’s pain or restriction of movement. The patient should if possible perform repeated movements, as this may alter the quality and range of the movement and may give rise to latent pain (McKenzie 1990).


Palpation

Palpate the soft tissues, noting the positions of vertebrae and myofascial trigger points (localised irritable spots within skeletal muscle). These trigger points produce local pain in a referred pattern and often accompany chronic musculoskeletal disorders. Palpation of a hypersensitive nodule of muscle fibres of harder than normal consistency is the physical finding typically associated with trigger points (Alvarez and Rockwell 2002). Observe for local or referred pain, thickening of structures or stiffness. Remember that anomalies of the bifid spinous processes of the cervical vertebrae and differences in their spacing are not uncommon and may not be clinically significant (Maitland 2001). Soft­tissue changes, including sub­occipital thickening and shortening in the extensors and prominence, and thickening of the articular pillar of C2–C3 facet joints, are common in degenerative disorders. Soft­tissue changes around the cervicothoracic junction are also commonly found and may be referred to as a Dowager’s hump.


Bony anomalies

Osteophytes may be palpable at the C2–C3 facet joints in patients with pre­existing spinal pathology (Maitland 2001). Approximation of the spinous processes of C6–C7 is also a common feature.

Accessory spinal movements

With the patient prone, central pressure on the spinous processes C2–T6 and unilateral pressures on the articular pillars C2–T6 is applied by the physiotherapist, noting levels of stiffness, pain response, muscle spasm and areas of hypermobility.


Mechanical tension tests

The upper limb tension test (ULTT) is referred to as the SLR test of the cervical spine. This test mobilises the brachial plexus and particularly biases the median nerve to determine the degree to which neural tissue is responsible for producing the patient’s symptoms. Certain movements of the arm, shoulder, elbow, wrist and hand, and, similarly, the neck and the lower limb, can cause neural movement in the cervical spine. These tests are so important that all physiotherapists should know and use them (Butler 1991). The physiotherapist depresses the patient’s shoulder, then adds in 90 degrees abduction, 90 degrees lateral rotation of the shoulder, elbow extension, forearm supination, and wrist and finger extension to the supine patient. Sensitising manoeuvres such as ipsilateral (same side) or contralateral (opposite side) cervical rotation and side flexion are added. Symptoms of pain, paraesthesia and restriction are noted and compared with the other side. Common findings will be reduced range or the reproduction of symptoms on the affected side.

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