Tuesday, November 3, 2009

Are your muscles dysfunctional? Assessing neck pain: Part 2

     One should not assess mechanical neck pain (MNP) in an attempt to locate a specific structure which is flawed. Rather, MNP is often a contribution of different factors which lead to an end result of pathology. These contributing factors are dysfunctional muscles. This is a continuation of Part 1 and will discuss methods of examining MNP.  

     Manual therapist often will perform examinations with the goal of developing a diagnosis. Test will be performed and objective findings recorded. However, often performing examinations in this manner can produce a lot of black and white while forgetting to addressee the gray areas. With MNP the gray areas can be the most important areas. 

     So how do I assess cervical muscle function?

     Firstly, when assessing muscle function one must understand this is an observational skill. Such a skill will improve with the experience of the examiner.  There are no objective criteria which will produce a positive or negative result. Furthermore, this fact alone will create discrepancies between examiners. What one person deems as dysfunctional another may not.

     1. The Cranial Cervical Flexion Test (CFFT)

    This test is designed to examine and train deep cervical flexor muscles such as the longus capitis and longus colli [1]. These particular muscles play an important role in the stability of spinal segments. By using this test, examiners can indicate if these muscles are dysfunctional. In addition, we can also purpose a cause for patients MNP. Furthermore, this test can also help guide the rehabilitation process by indicating which muscles need to be targeted. 

     The test incorporates two important components of the deep cervical flexion muscles 1) upper cervical flexion and 2) flattening of the cervical spine. Studies have found those with both traumatic and non traumatic neck pain to lack the ability to perform the CCFT. Furthermore, while performing the CCFT these subjects displayed an increase in EMG activity of the superficial cervical muscles. This is hypothesised to be due to a compensation of weak and inhibited deep cervical flexion muscles. 

     To perform this test the patient must be lying supine with the forehead and chin parallel to the table. To achieve this position often the head must be placed in a small opened head rest (chiro table). The purpose of this position is to place the neck in a neutral position not favouring flexion or extension of any kind.

     Instead of using an inflatable pressure sensor (as described in studies) one may use a blood pressure cuff to gage the patient’s pressure. Place the blood pressure cuff below the occiput and behind the neck. Inflate the blood pressure cuff until the space between the neck and the table is filled but not to produce pressure upon the neck.

The patient is then instructed to nod the chin towards the sternum. The movement should be done without creating flexion of the head as if one is attempting to do a sit up. This position is then held for 10 seconds and should be performed at a level high enough to raise the blood pressure cuff by 10mmHg. If testing for endurance then repeat the same movement 10 times.

     Inability to do the test or to increase the pressure indicates weakness of the deep cervical flexors [2]. Observe the following Video.

  Keep in mind this test can be used to also train patients who present with muscle dysfunction. Patients can be progressed by increasing pressure (4mmHg to 5 mmHg) or by simply increasing the number or reps.     
      2) The Link to Posture

     How do I assess if there is a postural component to my patients pain?

    Patients will experience neck pain with prolonged sitting, repetitive upper limb activities or while maintaining a sustained position. 

     Patients will show poor cervicalthoracic postural habits when asked to mimic the aggravating postures which create their pain. Sitting for example has been shown in those with MNP to produce an increased cervical lordosis. This lordosis occurs due to compensating for a progressive thoracic kyposis over time from prolonged sitting.   
     Patients will report lessening of symptoms with postural correction strategies. 

3) The Link to the Scapula

     Patients with MNP have been linked to dysfunctional axioscapular muscle activity. These are patients who will experience their neck pain while performing repetitive task of the upper limb. Muscles such as the upper Trapizium and the Levator scapulae can be the source of this connection. These muscles have the ability to produce abnormal forces through spinal segments due to the scapula dysfunction.
     Scapular dysfunction can be assessed in multiple ways and would require an additional column. However, a good test is to first have a patient perform an aggravating activity which involves upper limb movement. Often I will try to reproduce the patient’s pain by having them bounce a ball repetitively against a wall with their arms elevated overhead. A connection can be made to their neck pain if pain is reproduced.
     Now have the patient perform the same task as before but with their scapula repositioned in the proper manner. This repositioning can be performed manually with either the scapular retraction test or scapular assistance test. Both test are often used to test shoulder pathology and purposed by Kibler. Another method to help reposition the scapula is the use of tape. If the patient now can perform the same task but with symptoms lessened or resolved this indicates they may benefit from scapular setting exercises in their treatment plan.
     In summary, one should be aware of multiple observational strategies to assessing MNP.  These three valuable points will be overlooked if a practitioner simply focuses on objective findings and questionnaires. Pain may be resolved but could reoccur if these factors are not addressed. So remember don’t just examiner but assess and observe.
Falla, D., Jull, G., & Hodges, P. (2004). Patients With Neck Pain Demonstrate Reduced Electromyographic Activity of the Deep Cervical Flexor Muscles During Performance of the Craniocervical Flexion Test Spine, 2108-2114 DOI: 10.1097/01.brs.0000141170.89317.0e   FITZGERALD, K. (2008). D.J. Magee, Orthopedic Physical Assessment (fifth ed.), Saunders Elsevier (2008) ISBN 978-0-7216-0571-5 1138 pp., Hardback, illus, CD-ROM, AUD 124.00 GBP 48.99. International Journal of Osteopathic Medicine, 11 (2), 69-69 DOI: 10.1016/j.ijosm.2008.02.002   O’Leary, S. (2009). Muscle Dysfunction in Cervical Spine Pain: Implications for Assessment and Management Journal of Orthopaedic and Sports Physical Therapy DOI: 10.2519/jospt.2009.2872


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