Cervical range of motion

Cervical range of movement (ROM) assesses the quality and quantity of movement, as well as symptom response to movement in the cervical spine.

How to

Cervical ROM is most reliably assessed using an inclinometer held in the midline of forehead (between earlobes) for lateral flexion on the vortex of the head in line with the nose for flexion and extension.

When and why

• Assessment of cervical ROM is recommended as part of routine assessment for whiplash patients. 
• Reduced cervical ROM is an adverse prognostic indicator.^1,2  
• Changes in cervical ROM can be used as an outcome measure related to cervical impairment. 
• Reliability of inclinometer method is 0.84–0.96.³

Results

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Cranio-cervical flexion test

Cervical flexor muscle performance can be assessed using the cranio-cervical flexion test (CCFT). This test assesses the relative activation of deep (longus coli and longus capitus) vs superficial (sternocleidomasotid) cervical flexors.^1,2

How to

1. Prepare: to conduct the assessment.

2. Analysis: assess the pattern of cranio-cervical flexion movement.

3. Endurance: assess the endurance of the deep cervical flexors using a pressure biofeedback unit. The endurance capacity should be assessed as the number of 10 second hold repetitions correctly performed at the stage assessed (range 20–30mmHg).^1,2

When and why

• Indicated when impairment of cervical flexion control is suspected, such as in whiplash.
• Enables assessment of cranio-cervical flexion control impairment and whether the impairment is relevant to a patient’s pain and disability. 
• Patients often report difficulty lifting the head off the bed, report that their head feels heavy or they can’t control their head during cervical extension.
• Poor performance of the CCFT has been equated with EMG electrode data.³

Results

Normative values for the CCFT are >10 repetitions correctly performed above 26mmHg.^1,2

For a demonstration watch the video below.

References

1 Jull et al. Journal of Manipulative and Physiological Therapeutics 2008; 31:525-33.  

2. Jull et al. (2008); Clinical Assessment: Physical Examination of the Cervical Region. In Whiplash, Headache and Neck Pain; Research-based Directions for Physical Therapies, Sydney: Churchill Livingstone.

3. Falla et al. Spine 2004; 29:2108-14.

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Cervical flexor endurance

Cervical flexor endurance can be assessed using a simple, cost-effective test that does not require any instrument except for a stopwatch. The test position used in this test is intended to increase the contribution of the deep neck flexors during the movement.

How to

The test is performed with the patient in crook-lying on a plinth, with hands on the abdomen. Position the patient’s head in slight upper neck flexion by placing your left hand on the table just below the occiput. The head of the plinth can be elevated at first to decrease the difficulty of the test if required.

1. Ask the patient to gently flex his or her upper neck and lift his or her head off your hand (approximately 2.5 cm above the plinth) while retaining the upper neck flexion.

2. Provide verbal feedback (“tuck your chin in” or “hold your head up”) when the head touches your left hand during the test.

3. Measure holding time in seconds.

4. Guide the patient through the motions required for performance of the test 2 times.

Terminate the test when: (whichever occurs first)

• If the patient is unable to maintain a lifted head position and loses the neutral position (i.e. ‘pokes’ chin out)
• If the patient is limited by an increase in pain or discomfort.
• At 1 minute

When and why

• Enables the assessment of cervical flexor endurance impairment and whether it is contributing to patient’s pain and disability.
• This test for cervical flexor endurance has been found to have moderate to excellent intra-rate and inter-rater reliability,² even when measured only once as is usual in the clinics.² It has been used in a number of clinical trials which measured deep cervical flexor endurance among the outcomes in people with and without neck pain. 

Results

Examples of typical hold times

• Without neck pain: 38.95 seconds (mean, SD 26.3)²
• With neck pain: 24.1 seconds (mean, SD 12.8)²
• Minimal detectable change: 17.8³
• Minimal detectable change: 45.34⁴

References

1. Jull et al. Manual Therapy 2004; 9:89-94.

2. Harris et al. Physical Therapy 2005; 85:1349-55.

3. Edmondston et al. Journal of Manipulative and Physiological Therapeutics 2008; 31:348-54.

4. Juul et al. BMC Musculoskeletal Disorders 2013; 14:339-54.

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Cervical extensor test

The cervical extensor test is described as a test to assess for impairment of neuro-muscular control of the deep cervical extensors. The reliability and validity of this test is yet to be established. Despite this, it is recommended in patients with acute whiplash as it assesses impairment at lower loads than the endurance and strength tests, which may aggravate symptoms.

How to

1. Position the patient in 4 point kneeling or prone on elbows.

2. Ask the patient to perform cervical flexion-extension motion whilst maintaining the upper cervical spine in neutral.

3. Assess movement patterning. Faulty patterning may include jerky movement, lag of the lower cervical spine in retuning to neutral and dominance of cranio-cervical extension.

You can attempt to facilitate activation of the deep cervical extensors by giving resistance at the segmental vertebral arch.^1,2

When and why

Indicated for use in patients with whiplash who report a feeling of weakness in their cervical spine (eg inability to hold head up).

Enables assessment of cervical extensor impairment and whether the impairment is relevant to the patient’s pain and disability. 

Results

Normative values have not yet been published. However, you can expect a patient with normal cervical extensor control to conduct at least 10 repetitions held for 10 seconds.

References

1. O’Leary et al. Journal of Orthopaedic & Sports Physical Therapy 2009; 39:5:324-33.

2. Schomacher & Falla. Manual Therapy 2013; 18:360-6. 

 

 

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Cervical extensor endurance

Cervical extensor endurance can be assessed using a submaximal test that can be done without using complicated instruments.

How to

Set-up¹

1. Position the patient prone, lying on a plinth with their arms at their side and head over the end of the plinth, supported by you.

2. Place a strap at the level of T6 to support the upper thoracic spine. Fix a band around the head with a fluid inclinometer attached to the band over the occiput.

3. Suspend a 2kg weight from the headband so that the weight is located just short of the floor.

4. Ensure the patient’s head is in a neutral sagittal plane position

The test begins when the assessor removes the support of the patient’s head.

Test

1. Ask the patient to hold the position, with cervical spine horizontal and chin retracted.

2. Measure the holding time in seconds.

Terminate the test when: (whichever occurs first)

• if the neck position changes by more than 5° from the horizontal as measured by the inclinometer
• if patient could no longer hold the position due to pain or discomfort
• at 3 minutes and 20 seconds.

When and why

Indicated in people with whiplash associated disorders because they have been shown in previous trials to have weakness of cervical extensors.^2,3

Enables the assessment of cervical extensor endurance impairment and whether it is contributing to patient’s pain and disability.

Results

Examples of typical hold times

Without neck pain: 229.9 seconds (mean, SD 109.1s)⁴

With neck pain: 143.8 seconds (mean, SD 105.6s)⁴

Healthy controls: 178.3 seconds⁴

Neck pain group:110.2 seconds⁴

References

1. Edmondston et al. Journal of Manipulative and Physiological Therapeutics 2008; 31:348-54.

2. Lee et al. Journal of Manipulative and Physiological Therapeutics 2005; 28:25-32.

3. Elliott et al. Manual Therapy 2008; 13:258-65.

4. Shahidi et al. BMC Musculoskeletal Disorders 2012; 13:215.