Check for worsening/improving pain or increasing decreasing pain
Repeat up to 10 times
Cervical distraction and compression
Compression gradually load cervical spine
pressure through top of skull
test in neutral, flexion, extension
Distraction gradually unload cervical spine
lift up under occiput
test in neutral, flexion, extension
Assess signs and symptoms by using combined movement of rotation, sidebending, flexion or extension.
Quadrants: posterior left and right
anterior left and right
Anterior quadrant: flexion with sidebending and rotation to the same side. This opens up the IVF on the opposite side.
Posterior quadrant: extension with sidebending and rotation to the same side. This closes the IVF on the same side and puts the facet on the same side in close packed position.
Perform posterior quadrant test passively. If this is negative for reproduction of symptoms, carefully add vertical compression.
Valuable when relevant signs and symptoms are not reproduced with active/passive/resisted movements.
Assess pain behavior with prolonged posture in flexion and extension.
Segmental mobility testing
Shoulder abduction test
Patient seated or lying. Put hand on top of head. Decrease of symptoms is indicative of C5-6 nerve root compression.
Patient seated. Passively rotate head left, right. Then hold head still, while patient turns his trunk left, right. If dizziness occurs in both cases, suspect vertebral artery insufficiency. If dizziness only occurs with passive rotation of the head, suspect inner ear problems.
Craniovertebral Scan The craniovertebral region is a critical area that may be the site of serious pathology. An acute cervical patient may have a life threatening injury requiring emergency medical attention. Before attempting to mobilize the cervical spine, two factors need to be taken into consideration. Ruling out the presence of cardinal signs and symptoms is a priority. They are considered to be extremely important as they suggest either vertebral/basilar artery insufficiency, or cervical cord compression. If such symptoms can be initiated, reproduced or aggravated by stressing the vertebral artery or by passive linear motions to the craniovertebral joints, then it’s reasonable to assume that there is possible insufficiency of the vertebral artery or that instability exists within the craniovertebral joint complex.
We think it’s prudent to test for upper cervical instability prior to testing the vertebral artery, as this involves sustained endrange rotation, which can possibly compromise the spinal cord if there would be underlying instability.
Cardinal signs and symptoms
Signs/symptoms suggestive of cervical cord compression:
Bilateral or quadrilateral limb paresthesiae, either constantly or reproduced/aggravated by head or neck movements.
Positive Babinski or Hoffman’s
Arm and leg weakness
Lack of coordination bilaterally
The vertebral artery arises from the first part of the subclavian artery and passes upward on the longus colli to enter the transverse foramen of C6. Occasionally it may enter the bone at the 5th, 4th or 7th cervical transverse foramen. It then ascends from C6 to C1. After emerging through the transverse foramen of C1, it winds around the articular pillar and together with the 1st cervical nerve and veins pierces the posterior atlanto-occipital membrane to enter the cranium through the foramen magnum. On the anterior side of the brainstem it joins its fellow to form the basilar artery, before entering the foramen magnum.
The vertebral arteries contribute about 11 percent of the total cerebra blood flow, the remaining 89 percent being supplied by the carotid system. Asymmetry in the size of the two VA’s is common. Indeed, complete interruption of blood flow in one VA may be asymptomatic as long as there is a normal configuration in the circle of Willis and adequate flow through the other VA. Symptoms will occur when the blood supply to an area is critically reduced. This will depend ultimately on a balance between compensatory and compromising factors.
Provocative positional testing is frequently used in practice. It is intended to provide a challenge to the vascular supply to the brain, and the presence of signs or symptoms of cerebrovascular ischaemia during or immediately post testing is interpreted as a positive test.
Despite endorsement by guidelines and common clinical usage, current research does not support the contention that provocative positional testing can accurately identify patients at risk for cervical artery disease. Vertebral artery testing procedures have a sensitivity and specificity that approximates zero. This indicates a high likelihood of false negative findings.
Test procedures for the vertebral artery also hold a certain risk, and screening tests will not identify all patients at risk of suffering adverse reaction to cervical manipulation. There is also disagreement on what constitutes a clinically meaningful change in blood flow on cervical movement. It should be reiterated that there is no known method for testing the intrinsic anatomy of the vertebral artery. Doppler studies (Arnold, 2004) have shown that only full range cervical rotation and a pre-manipulative hold at C1-2 stresses the vertebral artery sufficiently to demonstrate reduction of bloodflow. Therefore the Clinical Guidelines of the Australian Physiotherapy Association recommend that only rotation be used to test for VBI.
Risk factors associated with cervical arterial dysfunction
History of trauma to cervical spine / cervical vessels
Patient sitting. Palpate C 2 with index finger while sidebending head to the right. Normal: should feel immediate movement of C 2 to the opposite side of sidebending.
Transverse ligament Patient supine. Anterior movement of occiput and C 1 on C 2. Normal: C 2 should follow immediately.
Transverse plane stability.
Medial pressure on TP of C 1 while stabilizing the opposite TP. Should be no movement or crepitus (Jefferson fracture).
Upper motor neuron tests
Hoffman’s. Flick patient’s middle finger. Positive when there is a flexion pattern of thumb and index finger.
Examination Performed when stability tests are negative and there are no upper motor neuron signs
Minimal testing recommended includes the following:
Sustained end range cervical rotation to the left and the right. Maintain each position with overpressure for 10 seconds 9 or less if symptoms are provoked) and on release, a period of 10 seconds should elapse to allow for any latent response to the sustained position. The patient is asked about dizziness during each test, and the eyes are observed for the presence of nystagmus
The position or movement that provokes symptoms as described by the patient.
Sustained mobilization position
Specific questioning re. production of symptoms suggestive of VBI is essential and should be done
Immediately before and after a cervical manipulation
During and immediately after a technique involving endrange rotation