Cervical Assesment
- Fysiobasen
- Oct 5
- 13 min read
A diagnostic process aims to align the patient’s clinical presentation with the most effective treatment approach. A crucial part of this process is determining whether the patient is suitable for physiotherapy intervention¹. To achieve this, three key elements must be assessed during the examination:
Core Diagnostic Components
1. Exclude Serious Pathological Conditions
Identify whether there are any severe diseases that require referral for further medical evaluation or surgical intervention.
2. Identify Movement and Functional Dysfunctions
Assess impaired motor control, sensorimotor disturbances, and dysfunctions involving connective or neural tissues. Confirm or rule out specific conditions where possible.
3. Identify Contributing Factors
Determine factors that may influence deviations from the expected recovery pattern, including psychosocial or systemic contributors.
Subjective Examination
A thorough subjective assessment is essential to understand the patient’s complaints and develop an effective treatment plan. This part of the evaluation provides critical information that helps identify red and yellow flags, while also giving valuable insight into the patient’s functional limitations and overall experience.
Patient History
The patient’s medical history is often the most valuable source of information to rule out serious pathology and guide the objective assessment. The following components should be evaluated:
Past Medical History (PMH)
Document any previous injuries, illnesses, or chronic conditions that could affect the patient’s current symptoms.
History of Present Illness (HPI)
Explore the onset and development of symptoms:
When and how did the pain start?
What aggravates or relieves the symptoms?
Are the symptoms constant or intermittent?
Regional Symptoms
Ask about discomfort or pain in other regions such as the thoracic spine or shoulders to identify referred pain or related dysfunctions.
Outcome Measures
Use validated clinical outcome tools to assess functional status and pain:
Neck Disability Index (NDI)
Patient-Specific Functional Scale (PSFS)
Red Flags
Patients with cervical pain must be screened for red flags that may indicate serious or life-threatening conditions. The following table summarizes common red flags:
Condition | Signs and Symptoms |
Cervical Myelopathy | Sensory disturbances in the hands, hand muscle atrophy, unsteady gait, Hoffman’s reflex, Babinski, clonus, hyperreflexia, bowel/bladder dysfunction |
Neoplastic Conditions | Age >50 years, previous cancer, unexplained weight loss, constant pain unrelieved by rest, night pain |
Upper Cervical Ligament Instability | Post-trauma, rheumatoid arthritis, Down syndrome, occipital headache, severe ROM limitation, myelopathic signs |
Vertebral Artery Insufficiency | Drop attacks, dizziness, dysphasia, dysarthria, diplopia, nausea, ataxia, positive cranial nerve findings |
Systemic Conditions | Temperature >38°C, BP >160/95 mmHg, resting HR >100 bpm, fatigue, resting RR >25 bpm |
Cervical Fracture | Post-trauma injury — follow Canadian C-Spine Rules to determine imaging necessity⁵ |
Yellow Flags
Yellow flags refer to psychosocial factors that can contribute to chronic pain and prolonged disability. Recognizing and addressing these is critical for successful rehabilitation.
Psychosocial Factor | Description |
Fear of Movement (Kinesiophobia) | Patient believes that pain is harmful and avoids movement or activity until symptoms disappear. |
Passive Therapy Attitude | Patient depends on rest or medication and avoids active engagement in therapy. |
Symptom Exaggeration | Can be assessed using the Pain Catastrophizing Scale (PCS). |
Depression and Anxiety | Screen with Beck Depression Inventory (BDI) or Depression Anxiety Stress Scale (DASS). |
Clinical Relevance
The subjective examination forms the foundation for all subsequent clinical reasoning. By integrating patient history, red flag screening, and yellow flag identification, the therapist can tailor the examination and treatment plan to the patient’s specific presentation, ensuring a holistic and evidence-based approach.
Investigations
Radiological Assessments
Radiological imaging may be necessary to identify or rule out serious conditions. Common investigations include:
Canadian C-Spine Rules: A positive result requires radiological referral⁵.
Cervical X-ray: Commonly used to identify fractures, although CT scans are more sensitive⁵.
MRI of the Cervical Spine: Recommended for patients with rapidly worsening neurological symptoms⁵.
Red Flag Referrals: History of cancer, suspected vertebral artery disease, or instability warrant urgent imaging⁵.
Outcome Measures
Neck Disability Index (NDI)
Property | Description |
Content | 10 items: 7 related to ADL, 2 to pain, 1 to concentration⁵ |
Scoring | 0–5 points per item; total score expressed as percentage⁵ |
Interpretation | Higher scores indicate greater disability⁵ |
Change Scores | MDC: 5 (10%), MCID: 9.5 (19%)⁵ |
Reliability | Test–retest ICC = 0.68; valid for cervical radiculopathy⁵ |
Patient-Specific Functional Scale (PSFS)
Property | Description |
Purpose | Patient identifies three activities limited by symptoms or injury⁵ |
Scoring | 0–10 scale per activity; average of three scores = total⁵ |
Change Scores | MCID: 2.0 points for cervical radiculopathy⁵ |
Reliability | Test–retest ICC = 0.82⁵ |
Performance Testing
Performance-based assessments evaluate the patient’s functional capacity and progress over time.A common approach is to use an asterisk sign to identify specific movements or activities that reproduce symptoms.
Example: Ask the patient to look over their shoulder as if checking the blind spot. Note when symptoms appear, and reassess after intervention⁵.
Goal: Reduced symptom intensity or increased range of motion indicates functional improvement⁵..
Cervical Clinical Tests and Treatment Goals
A systematic evaluation of cervical pain should include specific clinical tests to confirm or rule out relevant conditions⁵. These tests help determine the underlying dysfunctions and guide individualized treatment strategies based on clinical findings and functional outcomes.
Clinical Tests for Cervical Conditions
Neck Pain with Mobility Limitations
Active Cervical Range of Motion (AROM)
Flexion-Rotation Test
Segmental Mobility Testing in the cervical and thoracic spine⁵
Neck Pain with Radiating Symptoms / Cervical Radiculopathy
Upper Limb Neurodynamic Tests (ULNTT)
Spurling’s Test
Cervical Distraction Test
Valsalva Maneuver⁵
Movement Coordination Impairments
Craniocervical Flexion Test (CCFT)
Cervical Flexor Endurance Test
Pressure Pain Threshold (PPT) Testing – using algometry to assess pain sensitivity and chronicity⁵
Objective Examination
Postural Observation
Posture should be assessed in both standing and sitting positions. Any postural deviations can be corrected during the assessment to evaluate their influence on the patient’s symptoms.
Common Postural Deviations | Description |
Cervical Spine | Protracted cervical spine or forward head posture |
Shoulder Girdle | Rounded or protracted shoulders |
Upper Thoracic Spine | Kyphotic/flexed, lordotic/extended, or neutral |
Mid-Thoracic Spine | Kyphotic/flexed, lordotic/extended, or neutral |
Movement Testing
Functional Movement
Before specific testing, the patient should perform a functional movement that reproduces their symptoms. This helps identify movement-related pain and serves as a performance-based outcome measure.
Cervical Motion Testing (AROM, PROM, Overpressure)⁵
Test | Description |
Baseline Symptoms | Document initial symptom location and intensity before testing. |
AROM | Measure flexion, extension, rotation, and lateral flexion in a neutral sitting position. |
Instruments | Inclinometer (ICC = 0.66–0.84); goniometer for seated rotation. |
Overpressure | Apply gentle overpressure at end range to assess end feel and pain response. |
Combined Movements | - Retraction: Upper cervical flexion + lower cervical extension - Protraction: Upper cervical extension + lower cervical flexion - Quadrant Test: Extension + ipsilateral rotation + side bending |
Cervical and Thoracic Segmental Mobility Testing (PPIVMs and PAIVMs)⁵
Step | Description |
Patient Position | Prone |
Posterior-Anterior Mobilization | Apply oscillatory PA pressure to each spinous process |
Unilateral Testing | Test articular pillar mobility on both sides |
Pain Provocation | Document segmental pain reproduction |
Mobility Classification | Categorize as normal, hypomobile, or hypermobile |
Reliability and Validity:
Sensitivity: 0.82 (Negative LR = 0.23)
Specificity: 0.79 (Positive LR = 3.9)
Pain Provocation ICC: 0.42–0.79 (neck pain)
Upper Cervical Dysfunction ICC: 0.78–1.0 (headache patients)
Passive OA Joint Testing (Flexion/Extension)
Position: Supine, with head supported or slightly off the table.
Procedure:
Rotate head 20–30° to isolate facet orientation.
Apply anterior translation to assess extension restriction.
Apply posterior translation to assess flexion restriction.
AA Joint Mobility Test (Cervical Rotation in Flexion)
Position: Supine
Procedure:
Therapist flexes the cervical spine to isolate the AA joint.
Palpate C1 and perform controlled rotation to both sides.
Compare rotation symmetry; restriction may indicate dysfunction.
Muscle Strength Testing
Position: Supine or seated, depending on muscle group.
Evaluate: Strength of cervical flexors, extensors, and accessory muscles.
Use Manual Muscle Testing (MMT) grading to document deficits.
Palpation
Supine
Palpate sternoclavicular and acromioclavicular joints for tenderness or mobility restrictions.
Assess suboccipital muscles, upper trapezius, levator scapulae, and pectoralis minor for tightness or pain.
Prone
Palpate along the cervical and thoracic spinous processes and ribs 1–7.
Evaluate posterior-anterior rib motion and identify asymmetries.
Seated
Palpate for soft tissue texture changes and alignment deviations along the spinal groove.
Assess for scoliosis or muscle guarding.
Neurological Examination
Performed if the patient reports numbness, tingling, or weakness in the neck, shoulder, or arm, suggesting nerve root involvement.
Reflexes
Reflex | Nerve Roots |
Biceps | C5–C6 |
Brachioradialis | C5–C6 |
Triceps | C7 |
Manual Muscle Testing (Myotomes)
Movement | Nerve Roots |
Elbow Flexion | C5–C6 |
Elbow Extension | C7 |
Shoulder Flexion | C5 |
Shoulder Extension | C6–C8 |
Shoulder Abduction | C5 |
Wrist Flexion | C6–C7 |
Wrist Extension | C6–C7 |
Finger Flexion | C7–C8 |
Finger Extension | C7–C8 |
Finger Abduction | T1 |
Sensory ExaminationDermatome Sensation Map
Dermatome | Sensory Region |
C3 | Occiput (posterior head and upper neck) |
C4 | Supraclavicular area (top of the shoulder) |
C5 | Anterior shoulder region (deltoid area) |
C6 | Lateral upper arm and forearm, including the thumb |
C7 | Posterior arm and forearm, extending to the middle finger |
C8 | Medial forearm and ring/little fingers (phalanges 4–5) |
T1 | Medial arm and axilla (inner upper arm region) |
Testing Procedure
Use light touch, pinprick, or cotton wool for each dermatome area.
Compare bilaterally for sensitivity differences.
Document absent, diminished, or normal sensation.
If abnormal, correlate findings with myotome and reflex changes for comprehensive diagnosis.
Cranial Nerve Testing and Differential Diagnosis of Cervical Conditions
A comprehensive cranial nerve examination provides essential diagnostic information about the integrity of the brainstem and peripheral nerves. It helps distinguish between central and peripheral causes of neck-related neurological symptoms and contributes to accurate classification under the ICF and ICD frameworks.
Cranial Nerve Examination
Vestibular and Optical Nerves (II, III, IV, VI, VIII)
Snellen Eye Chart
Assess visual acuity at a distance of 20 feet.
Test each eye individually while covering the other.
Pupillary Light Reflex
Shine a light into each eye and observe for pupil constriction.
Absence of constriction indicates possible dysfunction of Optic (II) or Oculomotor (III) nerves.
Extraocular Movements
Ask the patient to follow your finger horizontally, vertically, and diagonally.
Abnormal eye tracking or double vision may indicate impairment of Oculomotor (III), Trochlear (IV), or Abducens (VI) nerves.
Trigeminal Nerve (V)
Sensory Function
Test light touch and pain over the forehead, cheeks, and jaw.
Loss of sensation or numbness suggests trigeminal nerve involvement.
Motor Function
Ask the patient to clench their teeth while palpating the masseter and temporalis muscles.
Jaw deviation to one side indicates a Trigeminal lesion.
Facial Nerve (VII)
Facial Expression Tests
Ask the patient to perform:
Raise eyebrows
Close eyes tightly
Show teeth and smile
Puff out cheeks
Findings:
Inability to close eyes or drooping mouth corner → Facial nerve paralysis.
Unilateral LMN lesion → Bell’s palsy
Bilateral LMN lesion → Guillain-Barré
Unilateral UMN lesion → Stroke
Glossopharyngeal (IX), Vagus (X), and Hypoglossal (XII) Nerves
Voice and Articulation Assessment
Dysphonia: Hoarseness may indicate vocal cord weakness.
Dysarthria: Poor articulation reflects motor dysfunction.
Palatal weakness: Nasal tone or asymmetrical palate elevation on “Ahh.”
Accessory Nerve (XI)
Shoulder Elevation Test
Ask the patient to shrug both shoulders against resistance.
Inability to lift one or both shoulders indicates a spinal accessory nerve lesion.
Special Cervical Tests
Cranial Cervical Flexion Test (CCFT)【5】
Procedure | Description |
Position | Supine, neutral head position (support under occiput if needed). |
Equipment | Pneumatic pressure sensor inflated to 20 mmHg. |
Execution | Perform graded flexion at 22–30 mmHg, holding 10 s per level. |
Normal | Maintains 26–30 mmHg without superficial muscle activation. |
Abnormal | <6 mmHg increase, <10 s hold, or superficial compensation. |
Reliability | ICC = 0.81 – 0.93 (high). |
Neck Flexor Endurance Test【5】
Procedure | Description |
Position | Supine, chin tucked, head lifted 2.5 cm. |
Observation | Monitor chin tuck and head control. |
End Point | Head drops or contacts examiner’s hand >1 s. |
Reliability | ICC = 0.67–0.91 (healthy); 0.67 (neck pain). |
Upper Limb Tension Test (ULTT)【5】
Procedure | Description |
Position | Supine; sequence: shoulder depression → abduction (90°) → supination → wrist/finger extension → external rotation → elbow extension → cervical side bending. |
Positive | Reproduced symptoms, >10° side difference, or symptom change with cervical motion. |
Sensitivity | 0.97 Specificity: 0.22 +LR: 1.3 –LR: 0.12 |
Spurling’s Test【5】
Procedure | Description |
Position | Sitting, head rotated and side-bent toward pain. |
Action | Axial compression (~7 kg). |
Positive | Reproduction of radicular pain. |
Sensitivity | 0.50 Specificity: 0.86 +LR: 3.5 |
Distraction Test【5】
Procedure | Description |
Position | Supine, relaxed flexed head. |
Action | Traction force (~14 kg) under chin and occiput. |
Positive | Symptom relief or disappearance. |
Sensitivity | 0.44 Specificity: 0.90 +LR: 4.4 |
Valsalva Test【5】
Procedure | Description |
Position | Sitting; patient holds breath and exhales forcefully 2–3 s. |
Positive | Symptom reproduction (nerve root irritation). |
Sensitivity | 0.22 Specificity: 0.94 +LR: 3.5 |
Differential Diagnosis
Three Diagnostic Questions【7】
Is the condition visceral, systemic, or life-threatening?
Possible causes include:
Cervical myelopathy
Instability
Fracture
Neoplastic disease
Vascular compromise
Systemic/visceral disorder
What is the primary source of pain?
Understanding pain characteristics guides appropriate testing and management.
What systemic or psychosocial factors perpetuate pain?
Depression
Central sensitization
Fear-avoidance behavior
Passive coping strategies
Classification of Cervical Conditions (ICF & ICD)
ICF Category | ICD Equivalent | Key Diagnostic Indicators |
Neck Pain with Mobility Deficits | Cervicalgia, Thoracic spine pain | Limited AROM, hypomobility in cervical/thoracic spine. |
Neck Pain with Headaches | Cervicocranial syndrome, Headache | Pain provoked by cervical motion, abnormal CCFT results. |
Neck Pain with Movement Coordination Impairments | Cervical sprain/strain | Abnormal CCFT and endurance tests, poor motor control, muscle imbalance. |
Neck Pain with Radiating Pain | Spondylosis with radiculopathy, Disc disorder with radiculopathy | Positive ULTT, Spurling’s, Distraction, radicular symptoms. |
Diagnostic Criteria Summary
Criterion | Description |
Symptoms | Radicular or referred arm pain provoked by Spurling’s or ULTT; reduced by distraction. |
ROM Limitation | Cervical rotation <60° to affected side. |
Nerve Root Involvement | Weakness, altered reflexes, sensory loss. |
Treatment Response | Immediate symptom reduction after manual traction or mobilization. |
ICF and ICD Diagnostic Criteria: Neck Pain Classifications
ICF Category: Neck Pain with Radiating Pain
ICD Diagnosis: Spondylosis with Radiculopathy or Cervical Disc Disorder with Radiculopathy【5】
Criterion | Description |
Symptoms | Radicular or referred pain in the upper extremity that is provoked or intensified by Spurling’s test and Upper Limb Tension Test (ULTT), and relieved by the Distraction Test. |
Movement Limitation | Reduced cervical rotation (<60°) toward the affected side. |
Nerve Root Compression | Evidence of neurological involvement, such as diminished reflexes, muscle weakness, or sensory loss. |
Treatment Response | Reduction in radiating symptoms during or following initial assessment and intervention. |
ICF Category: Neck Pain with Mobility Deficits
ICD Diagnosis: Cervicalgia or Thoracic Spine Pain【5】
Criterion | Description |
Age | Typically under 50 years old. |
Pain Duration | Acute neck pain (<12 weeks) duration. |
Symptom Localization | Pain confined to the cervical region, without radiation into the upper limbs. |
Movement Limitation | Reduced cervical range of motion (ROM) on active and passive testing. |
Clinical Interpretation
These classifications are derived from the ICF impairment-based model and the ICD diagnostic framework.
Neck Pain with Radiating Pain typically involves nerve root irritation or compression, presenting with neurological signs, such as dermatomal pain, myotomal weakness, or altered reflexes.
Neck Pain with Mobility Deficits is characterized by localized mechanical dysfunction with limited cervical ROM, often due to joint hypomobility or muscular imbalance.
Both categories guide physiotherapists in targeted interventions, such as:
Manual therapy and segmental mobilization
Neural gliding techniques for radiculopathy
Cervical and thoracic mobility exercises
Postural correction and ergonomic retraining
Cervical Assessment – Complete Summary
Overview
A cervical assessment is a comprehensive evaluation used to identify the cause, nature, and severity of neck pain and related dysfunctions. The process guides physiotherapists in determining whether a patient is suitable for physiotherapy, identifying mechanical and neurological impairments, and ruling out serious pathology.The assessment follows a systematic clinical reasoning framework, integrating subjective history, objective testing, and diagnostic classification based on ICF and ICD standards【5】.
Key Objectives
Rule out serious pathology – Exclude life-threatening or medically urgent conditions that require referral (e.g., fractures, cancer, arterial compromise).
Identify movement and function impairments – Determine musculoskeletal and neuromotor dysfunctions affecting the cervical and thoracic regions.
Recognize contributing factors – Identify psychosocial, postural, or systemic elements influencing the patient’s symptoms or recovery.
Subjective Assessment
The subjective examination provides critical insight into the patient’s history, pain pattern, and functional limitations. It includes:
Medical history: Previous injuries, surgeries, or comorbidities that influence current symptoms.
History of present illness (HPI): Onset, duration, aggravating/alleviating factors, and symptom progression.
Regional symptoms: Exploration of referred pain in the thoracic spine or shoulders.
Outcome measures: Validated tools such as the Neck Disability Index (NDI) and Patient-Specific Functional Scale (PSFS).
Red and Yellow Flags
Red flags: Indicate serious pathology (e.g., cervical myelopathy, vertebral artery insufficiency, neoplasms, systemic conditions).
Yellow flags: Represent psychosocial factors such as fear-avoidance, catastrophizing, depression, or passive coping that may hinder recovery.
Objective Assessment
A structured objective examination validates findings from the subjective stage and quantifies functional limitations.
Postural Observation
Evaluates cervical and thoracic alignment (e.g., forward head posture, rounded shoulders, kyphosis).
Movement Testing
AROM/PROM with overpressure: Flexion, extension, rotation, and lateral flexion.
Combined motions and quadrant testing: To reproduce or relieve symptoms.
Thoracic and cervical segmental mobility (PAIVMs/PPIVMs): Identify hypo- or hypermobility.
Neurological Examination
Used when radicular symptoms (numbness, tingling, weakness) are reported:
Reflex testing: Biceps (C5–C6), Brachioradialis (C5–C6), Triceps (C7).
Manual muscle testing: Assesses strength across myotomes (C5–T1).
Sensory testing: Evaluates dermatomes C3–T1.
Cranial Nerve Examination
Assesses vestibular, optic, trigeminal, facial, glossopharyngeal, vagus, accessory, and hypoglossal nerve integrity (CN II–XII)【6】.
Palpation
Identifies tenderness, tone, and mobility of cervical musculature (e.g., suboccipitals, trapezius, levator scapulae).
Special Tests
Test | Purpose |
Cranial Cervical Flexion Test (CCFT) | Assesses deep cervical flexor control and endurance. |
Neck Flexor Endurance Test | Evaluates strength and fatigue resistance of anterior neck muscles. |
Upper Limb Tension Test (ULTT) | Detects neural tension or cervical radiculopathy. |
Spurling’s Test | Provokes radicular pain through cervical compression. |
Distraction Test | Relieves radicular symptoms, confirming nerve root involvement. |
Valsalva Test | Detects space-occupying lesions or disc pathology. |
Radiological Assessment
Radiological imaging is used when serious pathology or trauma is suspected:
Canadian C-Spine Rules guide imaging necessity.
X-ray/CT: Detects fractures or alignment issues.
MRI: Identifies soft-tissue pathology and nerve root compression.
Outcome Measures
Tool | Purpose |
Neck Disability Index (NDI) | Measures functional limitation due to neck pain. |
Patient-Specific Functional Scale (PSFS) | Evaluates patient-defined functional tasks. |
Both have strong reliability and sensitivity for tracking change in patients with neck dysfunction【5】.
Classification (ICF/ICD Framework)
1. Neck Pain with Mobility Deficits
Localized neck pain (<12 weeks)
Restricted cervical ROM
Hypomobility of cervical/thoracic segments
ICD: Cervicalgia or Thoracic Spine Pain
2. Neck Pain with Headache
Headache aggravated by neck movements
Limited upper cervical mobility
Positive Cranial Cervical Flexion Test
3. Neck Pain with Movement Coordination Impairments
Postural or repetitive strain injuries
Poor deep neck flexor control
Impaired strength, endurance, and coordination
4. Neck Pain with Radiating Pain (Radiculopathy)
Upper limb radiating pain
Positive Spurling’s, ULTT, and Distraction tests
Neurological deficits (reflex, strength, or sensation changes)
ICD: Cervical Disc Disorder with Radiculopathy or Spondylosis with Radiculopathy
Clinical Decision-Making
Cervical assessment integrates:
Symptom localization
Pain mechanisms
Functional limitations
Psychosocial factors
This comprehensive approach enables physiotherapists to formulate an accurate diagnosis, set individualized goals, and implement targeted interventions.
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