Neck Pain Care Pathway

7. Physical Examination

 

Overview: A comprehensive physical examination considers the biopsychosocial aspects of a patient’s condition, cultural sensitivity, informed consent, and the patient’s overall comfort. The selection and scope of assessments should be tailored to the individual clinical encounter, with a focus on increasing confidence in primary diagnostic considerations and refining differential diagnoses. This section provides an inventory of assessments rather than a prescriptive algorithm, allowing clinicians to choose appropriate measures based on the unique presentation and needs of each patient.

 

Additional Details for Selected Components:

 

• ​Neurological Examination: Record clinical findings for each:

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• Motor strength testing: E.g., C5: Shoulder abduction:  L 3/5, R 5/5

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• Strength testing: 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.

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• Strength testing: 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."

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• Reflex testing: E.g., C5: R 2/4, L 3/4

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• Cranial nerve testing:

  • CN I (olfactory): E.g., "Patient correctly identifies coffee and peppermint scents with both nostrils."

  • CN II (optic): E.g., "Visual acuity 20/20 bilaterally, visual fields full to confrontation."

  • CN III, IV, VI (oculomotor, trochlear, abducens): E.g., "Extraocular movements intact, pupils equal, round, reactive to light and accommodation (PERRLA)."

  • CN V (trigeminal): E.g., "Facial sensation intact in all three branches, masseter and temporalis muscles strong bilaterally."

  • CN VII (facial): E.g., "Symmetrical facial movements, patient can smile, frown, and raise eyebrows; taste test not performed."

  • CN VIII (vestibulocochlear): E.g., "Whisper test positive bilaterally, Romberg test negative."

  • CN IX, X (glossopharyngeal, vagus): E.g., "Gag reflex intact, palate elevates symmetrically, no difficulty swallowing."

  • CN XI (accessory): E.g., "Shoulder shrug strong and symmetrical, head rotation against resistance normal."

  • CN XII (hypoglossal): E.g., "Tongue midline without deviation, moves normally in all directions."

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

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

 

• Special/Orthopedic Tests:

• Select tests to use alongside a comprehensive clinical examination; the validity and reliability of these tests vary.

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• Document: Test side, results (positive/negative), and responses (e.g., “Spurling's R(-), L(+) patient reports pain to left arm”).

 

• Tests for Nerve Root Compression and Irritation (Radiculopathy):

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1. Spurling’s Test: Positive test: reproduces or exacerbates symptoms in the shoulder or arm.

2. Neck Distraction Test: Positive test: Relief of symptoms in the shoulder or arm.

3. Bakody Sign/Shoulder Abduction Sign: Positive test: Relief of symptoms in the shoulder or arm.

4. Valsalva Maneuver: Assesses presence of potential space-occupying lesion (e.g., disc herniation). Positive test: exacerbates person’s neck pain, arm pain, or both.

5. Upper Limb Tension Tests (ULTT): Positive test: reproduces or exacerbates symptoms in the arm.
    

• Tests for Common Neck Pain:

1. Cervical Compression Test: Positive test: reproduces pain in the neck.

2. Cervical Kemp’s Test: Positive test: reproduces pain in the neck.

 

• 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.
    

• Tests for Myofascial Pain

1. Myofascial Trigger Point Examination: Positive test: localized pain and referred pain upon compression of trigger points.

 

• 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).