Keywords: Subjective Ax, objective Ax, Passive ROM, Active ROM, Sore neck, Strength Tests, Rotator cuff tests, Special tests, Differential Diagnosis, Red flags neck.
Physiotherapy Neck Assessment (Ax)
- HPC –Trauma/insidious onset
- Type of work (Sedentary/manual)
- Cough/sneeze cause pain?
- Sleeping Positions/ Number of pillows.
- Do they have headaches/nausea/ dizziness, drop attacks?
What does this tell you?
These are the special questions which may indicate that something more sinister may be going on. Patients should be referred immediately back to the GP with your concerns noted. Ask a seniors advice on the severity of these symptoms and whether and A and E referral is more appropriate. Mechanism of Injury is important here, if they fell from a height, lost conciousness or have neck pain this may indicate a cervical fracture.
- Bilateral pins and needles or numbness
- Dizziness/Visual disturbances/ Nausea / Difficulty swallowing/Drop attacks.
- Waking at night with no positional relief/ Night sweats.
- Midline neck pain with history of trauma and the patient is unable to rotate more than 45 degrees actively (?cervical fracture)
- Has the neck pain been caused in an accident? Is there an insurance claim in process? Could this be a barrier to recover? To find out more about insurance click here.
The objective examination gives you quantifiable measures to rule out what structures are involved and to reassess after treatment to determine improvement/deterioration. For example documenting that a lady has 50% right neck rotation will allow you to re-assess at her next treatment session and monitor improvement or deterioration. This should help guide you on whether a treatment has been effective and can help confirm a diagnosis.
- AROM – Cervical Flexion, Extension, Rotation, Side flexion, Retraction.
- Biceps(C5), Triceps(C7), Brachioradalis (C6) Hoffmanns Sign.
- Sensation (Dermatomes)
- PA Spinous processes
- PA Tranverse processes
What does this tell you?
“As a student I wanted everything to fit into a box, unfortunately it doesn’t. Take an anatomy book, pick a joint and list the structures that may be affected if it were to have a force through it in any direction. As you learn your anatomy you will discover the list becomes longer and longer. As a physiotherapist anatomy is your bread and butter which enables you to rule out structures that may be causing the issue. It is rare that only one structure is affected with no damage to surrounding structures so bear this in mind. The following is aimed as a rough guide to give you some ideas however is by no means an exhaustive list.”
- Try to establish the structure involved. Pain at the end of the day after work may suggest the cause is postural. Pain in morning could be due to inflammation or neck position whilst sleep ie too many pillows.
- Poor Quality of movement – Does the neck deviate to avoid joint compression or to avoid stretching soft tissue? Where is the restriction and what is causing it?
- Throughout movements where does the patent feel their pain? With SF is this because they are compressing a joint? if its is the opposite side is it because it is stretching tight tissues?
- Does the patient present with significant guarding and unwillingness to move.
- Pins and needles of paraesthesia (numbness) in the arm or hand? This normally suggests a neural element which maybe coming from the neck or compression of the nerve somewhere along its course.
- If you press on a structure and this reproduces the patients symptoms this may suggest referred pain is occuring (ie C5 unilateral AP/PA the patient may feel symptoms in the C5 dermatomal region).
Active movements are assessed first. What is causing the restriction? Is it restricted by pain/stiffness?
(If the movement is painful with active movement but not on passive this may indicate the muscle is the source of the problem. If the pain is elicited on AROM and PROM this suggests that the structures on stress(ie tight) are causing the pain or perhaps tissues are being compressed?)
Passive movements are those performed by the physiotherapist or surgeon. They allow structures to be tested without patient effort to help to identify the structure/structures involved. One position for this is to have the patient supine, take the full weight of the head and perform ROM gently. The range, pattern of movement, end feel and degree of pain are all noted.
Posture, repetitive movements and prolonged positions can contribute to neck pain.
Compression – Patient laterally flexes neck. Physio applies gentle over pressure. Positive sign- Reproduction of symptoms (Radicular pain in ipsilateral side of lateral flexion)
Vertebral Artery Test (There is must controversy surrounding this test due to its provocative nature. Use at your own risk)–Patient performs extension and rotation of cervical spine (ie looking back over shoulder). Positive Sign: Reproduction of symptoms. Dizziness, light headedness
Distraction – Patient sitting. Physio places one hand under patients chin and other around occiput. Physio slowly lifts head. Positive sign – Symptoms are relieved when cervical spine is distracted.
Quadrant Position – Patient sitting. Patient performs combined extension, lateral flexion and rotation (ie decreases size of intervertebral foramen). Positive sign- Reproduction of symptoms. Nystagmus if vertebral artery compressed.
Upper limb Tension Test – (Median Nerve bias) Patient supine. Depression of the Shoulder, Glenohumeral abd (1100), shoulder ER (900) supination, wrist and finger extension. Click here for demonstration. Positive Sign- Reproduction of symptoms, radicular pain.
Upper limb Tension Test – (Radial Nerve bias) Patient supine. Depression and slight abduction of shoulder (100), elbow extension, pronation, wrist and finger flexion, ulnar deviation. Positive Sign -Reproduction of symptoms, radicular pain.
Upper limb Tension Test – (Ulna Nerve Bias) Patient supine. Shoulder depression and abduction (100), elbow flexion, pronation, wrist extension and then abduction of the arm.
Hoffmanns sign –Flick of distal phalanx (middle finger) into extension. Normal reaction (no response). Positive sign-Induced flexion of fingers/thumb.
Possible conditions include:
- Cervical degenerative joint disease
- Muscle strain or contusion
- Acute torticollis/wry neck (Acute facet locking)
Things seniors wished they’d known as a student:
- Be careful with sensitive questions ie ask – “Have you ever received radiotherapy or chemotherapy? ” rather than “Have you had cancer?”
- If you are unsure of someones age it may be better to ask “Are you working?” rather than “Are you retired?” to avoid offending anyone. If they are retired you could ask “How do you fill you days?” Many will volunteer in charity shops, attend coffee mornings or garden which may give you clues to the cause of symptoms.
- When performing PROM in supine explain to your patient what you are doing. People who are used to seeing chiropractors may be expecting a Grade 5 manipulation. Often a bit of reassurance will allow you to achieve full relaxation and get a true picture of soft tissue tension and joint stiffness.
- When discussing posture I have found it useful to say “None of us have an ideal posture but these factors “…..” will increase the strain on joints, soft tissues, and therefore increase pain.” I have found that explanation of a problem, particularly regarding forward head posture, increases compliance with patients. If you offend a patient early on by insulting their posture sometimes they are less likely to believe your diagnosis. If a patient understands why you are doing a treatment they are more likely to continue with exercises and treatment.
Check your anatomy and improve skills by reading X-Rays and completing a self directed image interpretation course, brought to you by Heidi Nunn DCR (D) Pgcert.
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