Cervicogenic and Tension-Type Headaches Care Pathway

7. Physical Examination

 

A comprehensive physical examination should consider the biopsychosocial aspects of the patient’s condition, cultural considerations, and the necessity of obtaining informed consent. This approach is crucial for both new and existing patients, especially when they present with new complaints. Obtaining informed consent involves explicitly addressing the purpose and process of the examination, ensuring the patient understands and agrees to the procedures. Special care should be taken when contact is made in sensitive areas, prioritizing the patient’s comfort and understanding throughout the examination. Additionally, cultural awareness is essential in healthcare, as a patient's cultural background can significantly influence their perception and response to treatment. Practitioners should adapt their examination techniques and interactions to be respectful and sensitive to cultural differences, tailoring their approach to meet the specific needs and considerations of each patient.

 

Observation:

Abnormalities, asymmetries, posture, gait, movements, facial expression.

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Vitals:

Blood pressure, heart rate, respiratory rate, temperature. May include eye exam (e.g.., visual acuity, pupil response, fundoscopic examination).

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Range of Motion:

Cervical spine's active, passive, and resisted ROM in all planes (flexion, extension, lateral flexion, and rotation). Consider regional and segmental hypomobility, hypermobility, and aberrant movement patterns.

 

Palpation:

Identify areas of tenderness in the cervical spine and surrounding musculature.

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Neurological Examination:

Motor Strength:

• Key Observations: Asymmetry or weakness indicating nerve root involvement:

  • C5: Shoulder abduction.

  • C6: Wrist extension.

  • C7: Wrist flexion and finger extension.

  • C8: Finger flexion.

  • T1: Finger abduction/adduction.

• Record the clinical findings for each. e.g., C5: Shoulder abduction: L 3/5, R 5/5.

 

Sensory Examination: 

• Key Observations: Check for sensory deficits in upper extremities, corresponding to specific dermatomal distributions:

  • C5: Lateral arm.

  • C6: Lateral forearm, thumb, index finger.

  • C7: Middle finger.

  • C8: Ring and small finger, medial forearm.

  • T1: Medial arm.

  • T2: Axilla.

• Record the clinical findings for each. e.g., "Patient reports that they perceive the same for sharp, light, and vibration for C5, C6, C7, C8 and T1." "Patient reports a loss of perception of sharp and light for C7 on the right with all other sensations intact."

 

Reflexes: 

• Key Observations: Asymmetry or absence of reflexes can indicate nerve root compression or other neurological conditions.

  • C5: Biceps.

  • C6: Brachioradialis.

  • C7: Triceps.

• Record the clinical findings for each. e.g., C5: R 2/4, L 3/4.

 

Cranial Nerve Tests:

• CN I (Olfactory): Sense of smell.

  • Record Findings: E.g., "Patient correctly identifies coffee and peppermint scents with both nostrils."

• CN II (Optic): Visual acuity and visual fields.

  • Record Findings: E.g., "Visual acuity 20/20 bilaterally, visual fields full to confrontation."

• CN III, IV, VI (Oculomotor, Trochlear, Abducens): Eye movements, pupil response.

  • Record Findings: E.g., "Extraocular movements intact, pupils equal, round, reactive to light and accommodation (PERRLA)."

• CN V (Trigeminal): Facial sensation, mastication muscles.

  • Record Findings: E.g., "Facial sensation intact in all three branches, masseter and temporalis muscles strong bilaterally."

• CN VII (Facial): Facial expressions (smile, frown), taste (anterior 2/3 of the tongue).

  • Record Findings: E.g., "Symmetrical facial movements, patient can smile, frown, and raise eyebrows; taste test not performed."

• CN VIII (Vestibulocochlear): Hearing and balance.

  • Record Findings: E.g., "Whisper test positive bilaterally, Romberg test negative."

• CN IX, X (Glossopharyngeal, Vagus): Gag reflex, palate elevation, swallowing.

  • Record Findings: E.g., "Gag reflex intact, palate elevates symmetrically, no difficulty swallowing."

• CN XI (Accessory): Shoulder shrug, head rotation.

  • Record Findings: E.g., "Shoulder shrug strong, and symmetrical head rotation against resistance normal."

• CN XII (Hypoglossal): Tongue movements (deviation).

  • Record Findings: E.g., "Tongue midline without deviation, moves normally in all directions."

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Lower Motor Neuron Signs:

• Key Observations: Muscle atrophy, fasciculations, reduced muscle tone, symmetrical loss of function. May indicate a neurological condition (e.g., radiculopathy, peripheral neuropathy, ALS, spinal muscular atrophy).

• Record as: E.g., "LMN signs: Atrophy (yes/no), Fasciculations (yes/no), Muscle tone (reduced/normal), Function loss (symmetrical/asymmetrical)."

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Upper Motor Neuron Signs:

• Key Observations: Increased muscle tone, hyperreflexia, pathological reflexes (e.g., Babinski sign, Clonus). May indicate conditions affecting the central nervous system (e.g., cervical spondylotic myelopathy, multiple sclerosis, stroke, spinal cord injuries).

• Record as: E.g., "UMN signs: Muscle tone (increased/normal), Hyperreflexia (yes/no), Babinski sign (positive/negative), Clonus (yes/no)."

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Special/Orthopedic Tests: Select tests to use alongside a comprehensive clinical examination; the validity and reliability of these tests vary.
Record: For all tests, note the side tested, whether the test is positive or negative. Observational notes for the responses to the tests also inform the clinical picture. Note that the interpretation of "positive" can vary among clinicians. e.g., “Cervical flexion-rotation test R(-), L(+) reproduces headache symptoms.” Tests include:

 

Tests for Cervicogenic Headache:

1. Cervical Flexion-Rotation Test: Positive test: reproduces or exacerbates headache symptoms.

2. Myofascial Trigger Point Examination: Localized pain and referred head pain upon compression of trigger points.

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Tests for Meningitis:

1. Kerning’s Sign: Positive test: Resistance and pain in the neck and back when attempting to straighten a flexed knee from a 90° hip flexion position.

2. Brudzinski’s Sign: Positive test: Involuntary flexion of the hips and knees when the neck is flexed forward.
    

Advanced Diagnostics:
Imaging: Generally not recommended within the first six weeks unless red flags are present, to avoid unnecessary radiation exposure, overdiagnosis, and costs. Currently, there is insufficient evidence that routine imaging improves patient outcomes. Discuss the benefits and risks of imaging with patients, educating them on the role of imaging and reasons for deferring it initially when applicable. Imaging used in specific contexts should be discussed through shared decision-making (e.g., persistent pain and functional limitations).