MSK cervical spine assessment

The main aims of the examination process are to assess the severity of the presenting complaint (in terms of pain, functional disability and psychological impact), formulate the diagnostic triage and to evaluate how and to what extent physiotherapy can be helpful.

• Mechanical NSNP (95% of cases). No identifiable cause can be found in 90% of these presentations.
• Nerve root compression / irritation (Radiculopathy,< 5% of cases)
• Serious spinal pathology (<1% of cases)

The following information should be collected and documented through interviewing the patient:

• Symptom site/description using body chart and Numerical Pain Rating Scale (NPRS)
• Aggravating and easing factors
• History of present condition (HPC)
• Functional limitations
• Social history (employment status/nature of work/hobbies/family)
• Past Medical History (PMH)
• Drug history
• Previous treatment and outcomes/investigations and results
• Assessment of patient’s fears, attitudes and beliefs in relation to their impairment
• Identification of the patient’s agenda for consultation and their expectations of physiotherapy
• Evaluation of the patients understanding of the current problem
• Formulation of the diagnostic triage: -
  • Mechanical Neck pain
  • Nerve root compression / irritation
  • Serious spinal pathology

NB: Diagnosis should be kept under review and not presumed definitive.

Consider red flags and serious pathology guidance

There is a general consensus that the most important predictor of determining outcome post an episode of NSNP is the patient’s psychosocial status. Linton (2000) concluded that psychological factors are strongly associated with the transition from acute to persistent pain and disability, and that psychosocial factors generally have a greater impact on disability than biomedical and biomechanical factors. Although the work by Linton does not specifically relate to neck pain it is possible that many of the factors identified will also affect recovery. The following psychological dispositions are consistent predictors of poor outcomes (Waddell, 1996):

• A belief that pain is harmful or potentially severely disabling
• Fear avoidance behaviour (avoiding a movement or activity due to a misplaced anticipation of pain) and reduced activity levels
• Tendency to low mood and withdrawal from social interaction
• Expectation of passive treatment(s) rather than a belief that active participation will help
• It is therefore essential to screen for and document evidence of psychosocial barriers to recovery (yellow flags). These provide indicators on the risk of chronicity developing. An assessment of the psychosocial status of the patient should be made with regard to the following (Kendall et al., 2004):
  • A = Attitudes and beliefs about pain
  • B = Health behaviours
  • C = Compensation issues
  • D = Diagnoses and treatment issues
  • E = Emotions
  • F = Family
  • W = Work related issues (see blue and black flags)

If appropriate, screen for Blue flags. Blue flags are individually perceived occupational factors that impede recovery and return to work (RTW). Examples include low job satisfaction or inadequate support from supervisor.

Identify black flags. Black flags are actual (organisational) barriers to RTW. These relate to social security and healthcare systems. Examples may include adverse sickness policies or benefit systems.

A person is at risk of developing disability if there is a cluster of a few salient yellow flags or a group of less important factors that combine cumulatively.

Few studies addressing psychosocial issues have been conducted in patients with NSNP. A number of studies undertaken with patients with whiplash demonstrate mixed evidence to suggest anxiety and distress prolong pain.

The objective assessment should be tailored to the individual patient and their subjective history.
If an identifiable cause of neck pain is found, then the examination and treatment should be tailored accordingly. Evidence for the reliability and validity for the majority of diagnostic tests used by therapists is limited. Diagnosis is hence made on the basis of sound clinical reasoning. The objective examination should therefore focus on the patient’s functional abilities, cultural sensitivities and their willingness to participate as opposed to finding a physical cause of their neck pain or radiculopathy.

Assessment may include:

• Examination of posture
• Identification of structural deformities
• Neurological examination
• Range of movement/ functional movements
• Assessment of neural mobility
• Palpation
• Repeated movement testing
• Gait
• Vertebrobasilar insufficiency (VBI)

Neurological examination should always be undertaken whenever signs or symptoms are present outside of the cervical region or where neurological pathology is suspected. The cervical region is defined as the area between the superior nuchal line proximally to the spine of the scapula and superior border of the clavicle border distally.

This should incorporate an assessment of:

• Dermatomes
• Myotomes (Myotomal weakness should be recorded in relation to the Medical Research Council (MRC) grading system for muscle power (0 – 5)
• Reflexes (biceps jerk, triceps jerk, brachioradialis jerk)
  See Appendix 1

Consider assessment of additional Upper Motor Neuron tests (e.g. Babinski, Clonus, Hoffman’s).

On completion of the assessment the patient’s health problem in relation to their neck pain or radiculopathy should be defined. The therapist should be able to:

• Confirm the diagnostic triage (see 2.1)
• Consider formulating a clinical impression that attempts to identify the dominant cause of the patient’s pain/symptoms e.g. are the symptoms predominantly from the muscular, articular or nervous system and is there a dominant pain mechanism e.g. nociceptive, peripheral neuropathic or central sensitisation. There is some evidence to support the reliability of diagnosis with a sub-classification system e.g. McKenzie MDT. Generating a clinical impression facilitates the clinical reasoning process and may provide some patients with a better understanding of their condition
• Summarise the patient’s main complaints in terms of physical, psychological and, social factors.Where possible identify the dominant pain mechanism (nociceptive, peripheral neuropathic, central or sympathetic)
• Negotiate agreed goals and formulate a time directed treatment plan
• Identify and record appropriate outcome measures (refer to section 5.1)

LINTON, S.J., 2000. Psychological factors in neck and low back pain. In: A.M. NACHEMSON and E. JONSSON, eds, Neck and Back Pain: the Scientific Evidence of Causes, Diagnosis and Treatment. New York: Lippincott Williams and Wilkins. (Link here - link correct as at 12/11/2021)