Research-Based Examination of Patients with Neck Pain

Research-Based Activity Limitation Measures
Although there are no activity limitation measures reported in the literature associated with neck pain, the clinician may use the following questions to assess the patient’s activity limitations:

  • Pain level at end ranges of motion (look up, look down, look over shoulder)
  • Pain level after sitting for 2 hours
  • Number of times each night that pain disrupts sleep
  • Tolerance to sitting at computer desk in minutes or hours
  • Percentage of time you have experienced pain in past 24 hours
  • Number of headaches in previous week or month

Research-Based Outcome Measures
Two self-report outcome measures have been shown to have validity and moderate test-retest reliability.  The Neck Pain Disability Index (NDI) questionnaire is designed to enable the clinician to understand how much the patient’s neck pain has affected their ability to manage everyday activities.  There are 10 sections (2 related to pain, 7 related to function in activities of daily living and 1 related to concentration).  Each of the 10 sections on the questionnaire is scored separately (0 to 5 points) and then added up (maximum total = 50).  On each section, a “0” represents no pain or disability and a “5” represents maximal pain or disability. The NDI is a commonly used outcome measure to determine perceived disability in patients with neck pain.  The NDI has been shown to have good construct validity, adequate responsiveness and moderate test-retest reliability. The MCID of the NDI has been reported as 19-percentage points. (13)

Click on the following link for a downloadable pdf file of the Neck Pain Disability Index

The Patient Specific Functional Scale (PSFS) was created to offer patients a standardized outcome measure to report their perceived level of disability.  In the PSFS, patients are required to list three activities that have been affected by their neck pain and rate the amount of functional impairment on a 10-point scale (“0” = not able to perform activity and “10”= able to perform activity as well as before onset of symptoms). The final PSFS score is an average of the three scores. The PSFS has shown adequate validity and moderate reliability when used on patients with neck pain. (14)  These outcome measures are important to establish baseline function and disability and for re-testing periodically throughout the course of treatment to show change in functional status.

Research-Based Physical Impairment Measures
The eleven-point numeric pain rating scale has been shown to have moderate test-retest reliability and adequate responsiveness in the measurement of neck pain.  The minimum clinically important difference (MCID) is described as the smallest difference which patients perceive as beneficial.  The MCID of the numeric pain rating scale has been reported as 1.3. (13)

Measurement of cervical active range of motion has been used to classify patients into different subgroups of neck pain for the purpose of identifying patterns of efficacious treatment related to the individual subgroups.  The goal of this classification is to use the physical examination to identify groups of patients who are most likely to respond to a particular type of treatment.  It has been shown that limited cervical active range of motion is a clinical finding associated with patients in a proposed subgroup with a diagnosis of cervicalgia.(10)  For the classification of cervicalgia, it has been shown that the patient’s cervical active range of motion for flexion, extension, and lateral flexion were measured using a bubble inclinometer per the procedure used by Cleland, et al.(15)  For cervical flexion, the inclinometer was placed on the top of the patient’s head positioned in the sagittal plane, aligned with the external auditory meatus and then zeroed.  The patient was instructed to bend her head forward and take her chin towards her chest as far as possible.  For cervical extension, the patient was instructed to take her head back as far as possible.  For cervical lateral flexion, the inclinometer was positioned in the frontal plane and aligned with the external auditory meatus.  The patient was instructed to take their ear toward their shoulder as far as possible. For cervical rotation, a standard goniometer was used by placing the goniometer on the top of the patient’s head with the stationary arm aligned with the acromion process and the moveable arm aligned with the center of the patient’s nose.  The patient was instructed to turn her head and look over her shoulder as far as possible.  Measurements of cervical range of motion for flexion, extension and lateral flexion using an inclinometer and cervical rotation using a standard goniometer have been shown to have interrater reliability coefficients ranging from .66 to .78, which is considered moderate to good.(15)

Cervical and thoracic segmental mobility tests have been used to measure the physical impairment of single-joint movement and pain in the cervical and thoracic spine.  With the patient in prone, the clinician contacts the spinous process of each cervical vertebrae with their thumb.  Positioning them self directly over the patient and keeping the elbows extended, the clinician imparts a posterior to anterior oscillating force. This repeated over each thoracic vertebrae using the hypothenar eminence.  The test is considered to be positive if pain is reproduced at a vertebral segment during the test.  The examiner judges the mobility as hypomobile, normal or hypermobile based on the relative movement of each vertebral segment.  The test has been shown to have moderate validity and good reliability. (15,16) 

Cranial Cervical Flexion Test
The Cranial Cervical Flexion Test (CCFT) is a special test designed to measure a patient’s ability to initiate and maintain isolated cranial and cervical flexion. for a description and photo of the test) The CCFT is a clinical test of the action of the deep cervical flexor muscles, the longus capitis, and longus colli. Developed 15 years as both a clinical and research tool, it was devised in response to research indicating the importance of the deep cervical flexors in support of the normal cervical lordosis and motion segments and clinical observations of their impairment with neck pain. The CCFT could be described as a test of neuromuscular control. The specific features assessed are the activation and isometric endurance of the deep cervical flexors as well as their interaction with the superficial cervical flexors, especially the sternocleidomastoid. The patient activates the deep flexor muscles during the performance of five progressive stages of increasing craniocervical flexion range of motion. It is a low-load test performed in the supine position with the patient guided to each stage by feedback from a pressure sensor placed behind the neck. (17) Research has established that patients with neck pain disorders, compared to controls, have an altered neuromuscular control strategy during craniocervical flexion characterized by reduced activity in the deep cervical flexors and increased activity in the superficial flexors usually accompanied by altered movement strategies. (18) Furthermore, they display reduced isometric endurance of the deep cervical flexor muscles. The muscle impairment identified with the CCFT appears to be generic to neck pain disorders. These observations prompted the use of the craniocervical flexion action for retraining the deep cervical flexor muscles within a motor relearning program for neck pain patients, which has shown positive therapeutic benefits when tested in clinical trials. The construct validity of the CCFT has been verified in a laboratory setting by direct measurement of deep and superficial flexor muscle activity. The Cranial Cervical Flexion Test has also shown moderately high reliability. (17)

Cranial Cervical Flexion Test

Neck Flexor Muscle Endurance Test
The Neck Flexor Muscle Endurance Test (NFMET) is a test designed to determine the muscular endurance strength of the deep cervical flexor muscles (longus colli and longus capitus).  The test has been shown to be negatively correlated with cervical pain and dysfunction and patients with neck pain have shown clinically and statistically lower neck flexor muscle endurance scores. (19)  The test is performed with the patient in supine hook-lying (knees bent, feet flat) position on a plinth with their chin maximally retracted and maintained isometrically. The patient lifts their head and neck, maintaining the chin tuck, until the head was approximately 2.5 cm (1 in) above the plinth.  Once in position, the clinician places their hand between the plinth and the patient’s head and gives verbal commands to “Tuck your chin” and “Hold your head up” if the patient lowers their head at all.  The test is terminated when the patient can no longer maintain the lifted head and chin tuck position.  The neck flexor muscle endurance test has been shown to have moderate interrater reliability. (19)  

Deep Neck Flexor Endurance Test

Upper Limb Tension Test
The Upper Limb Tension Test (ULTT) is a special test performed to assess the mobility of nerves in the upper extremity to determine whether the patient’s upper quarter symptoms are elicited during the test. The ULTT is performed with the patient in supine on a treatment table.  The examiner sequentially introduces the following movements to put tension on the median nerve:

  • Scapular depression
  • Shoulder lateral rotation
  • Shoulder abduction to 90 degrees
  • Elbow extension
  • Forearm supination
  • Wrist and finger extension
  • Cervical side-bending (contralateral; ipsilateral)

Upper Limb Tension Test

A ULTT is positive with any of the following results:

  • Reproduction of part or all of the patient’s symptoms
  • Limited elbow flexion or wrist extension greater than 10 degrees compared to the ipsilateral side
  • Contralateral cervical side-bending increases the patient’s symptoms
  • Ipsilateral cervical side-bending decreases the patient’s symptoms

Regarding diagnostic accuracy, the ULTT has a high sensitivity, which means that the ULTT has a high degree of accuracy correctly identifying people with upper limb neural tension.(12)

Spurling’s Test
Spurling’s Test is a special test in which the examiner temporarily narrows the intervertebral foramen in an attempt to elicit the patient’s radicular symptoms.  With the patient in the sitting position, the examiner asks the patient to extend their neck and laterally flex toward the involved side.  The examiner then presses down on the patient’s with a force of 7 kg to further compress and narrow the intervertebral foramen.  A positive test is the reproduction of the patient’s radicular symptoms.  The Spurling’s test has a moderately high degree of specificity, which means it is accurate in correctly identifying people with intervertebral foraminal stenosis.

Foraminal Compression Spurling's Test

Distraction Test
The distraction test is a special test designed to increase the diameter of the intervertebral foramen in order to reduce or eliminate the patient’s cervical radiculopathy.  The test is not indicated if the patient does not have radicular symptoms. The test is performed with the patient in supine on a treatment table.  The examiner sits or stands at the head of the table and grasps under the patient’s head firmly holding the patient’s occiput with the hypothenar eminences.  The examiner then flexes the patient’s neck and applies a distraction/traction force of up to 14 kg / 35 lbs.  The test is positive if the patient’s radicular symptoms are reduced or eliminated.  The distraction text has been shown to have a high degree of specificity, which means that it is accurate in correctly identifying people that do not have intervertebral foraminal stenosis.(12)

Distraction Test

Now that we have looked at the examination of the patient with neck pain, we will look at treatments.

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