Cervical Assesment

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.

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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.

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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】

1. Is the condition visceral, systemic, or life-threatening?

   Possible causes include:

   • Cervical myelopathy

   • Instability

   • Fracture

   • Neoplastic disease

   • Vascular compromise

   • Systemic/visceral disorder

2. What is the primary source of pain?

   Understanding pain characteristics guides appropriate testing and management.

3. 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

1. Rule out serious pathology – Exclude life-threatening or medically urgent conditions that require referral (e.g., fractures, cancer, arterial compromise).

2. Identify movement and function impairments – Determine musculoskeletal and neuromotor dysfunctions affecting the cervical and thoracic regions.

3. 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.

Sources:

1. Blanpied PR, Gross AR, Elliott JM, Devaney LL, Clewley D, Walton DM, Sparks C, Robertson EK, Altman RD, Beattie P, Boeglin E. Neck Pain: Revision 2017: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health From the Orthopaedic Section of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy. 2017 Jul;47(7):A1-83.

2. Flynn TW, Cleland JA, Whitman JM. User’s Guide to the Musculoskeletal Examination: Fundamentals for the Evidence Based Clinician. Evidence in Motion. 2008.

3. Osman A et al. The Pain Catastophizing Scale:Further Psychometric Evaluation with Adult Samples. Journal of Behavioral Medicine. 2000; Vol.23(4): 351-365.

4. Rivest K et al. Relationships between pain thresholds, catastrophizing and gender in acute whiplash injury. Journal of Manual Therapy. 2010; Vol 15:154-159.

5. Childs JD et al. Neck Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Orthopaedic Section of the American Physical Therapy Association. The Journal of Orthopaedic Sports Physical Therapy. 2008;38(9):A1-A34.

6. O’Sullivan SB, Schmitz TJ. Physical Rehabilitation: Fifth Edition. Philadelphia: F.A. Davis Company; 2007.

7. Murphy DR, Hurwitz EL. A theoretical model for the development of a diagnosis-based clinical decision rule for the management of patients with spinal pain. BMC Musculoskelet Disord. 2007, Aug 3;8:75.