Cervical (Orthopedic)

Posture
Triage screen:
-End Range Rotation Test for VBI
-Modified Sharp Purser
-Alar Ligament Stability
Rule out shoulder and thoracic spine
Active repeated motions and overpressure for pain adaptive vs. pain non-adaptive
Passive repeated motions 
Passive accessory
-CPA (C2àupper aspect of T-spine)
-UPA (C2/C3àupper aspect of T-spine)
Palpation (trigger points, tinder areas)
Isolating movements
Muscle endurance 
-Jull Test (BP cuff, 10 bouts of 10 seconds)
-Scapular endurance test
-Neck flexor endurance test. Normative values: men=38.9 sec, women: 29.4 sec.
-Posterior neck endurance test
-Lateral lift test (sidelying)
-CkCues test
Confirmation Tests
-Cervical Flexion-Rotation Test for HA
-C1-C2 PA mobilization for HA
-UPA for cervical facet dysfunction
-Cluster for cervical radiculopathy: Spurling, ROM < 60 degrees, distraction test, and ULTT. When all 4 are positive, extremely high probability for cervical radiculopathy.
Passive Physiologic
Cervical passive physiologic upglide assessment and treatment
Cervical passive physiologic side glide assessment and treatment
Cervical passive physiologic sideglide-upglide combination assessment and treatment

Cervical Radiculopathy and/or Radicular Pain

Physical Examination
-Special Tests: 
ULTT: supine, depress shoulder, abduct shoulder to 110 deg, supinate forearm, extend wrist and fingers, ER shoulder, elbow extension, check for sensitivity with lateral neck flexion
Spurling’s Compression Test: cervical compression while slight lateral flexion.
Cervical Distraction Test
Valsalva Maneuver
Shoulder Abduction Test: neutral neck position, patient rests hand on head. Positive is pain relief.
Cervical Compression Test
Wainner’s Test Item Cluster for Radiculopathy: (+LR of 6.1 for ¾, +LR of 30.3 for 4/4)
        Ipsilateral C-Spine Rotation AROM < 60 deg (if right symptoms, right rotation would be limited)
        Spurling’s Test +
        Cervical Distraction Test +
        Upper Limb Tension Test +

Cervicogenic Headache

Physical Examination
-Special Tests: 
Cervical Flexion Rotation Test: supine, place neck in full flexion, passively rotate each direction to end-range. Positive is concordant pain, limited ROM to one side by >/= 10 deg compared to contralateral. 

Cervical Arterial Dysfunction

Physical Examination
-Special Tests: 
End-Range Rotation Test: seated and placed into end-range cervical rotation for 10 seconds. Positive for: nystagmus, pupillary dilation, dizziness, nausea, dysarthria, dysphagia, disturbances of hearing or vision, paresis or paralysis if patient has Vertebrobasilar Insufficiency (VBI).

Restricted 1st Rib

Physical Examination
-Special Tests: 
Cervical Rotation Lateral Flexion Test: seated and rotated away from side being tested and then laterally flexed moving ear toward chest. Positive if lateral flexion is blocked indicating rib hypomobility.
1st Rib Spring Test: supine, laterally flex neck to ipsilateral side and assess mobility with caudal/medial force onto 1st rib behind upper trap.

Acute Zygapophyseal Joint Arthropathy

Physical Examination
-Special Tests: 
Spurling’s Compression Test: cervical compression while slight lateral flexion.
Cervical Compression Test

Cervical Spine Myelopathy

Physical Examination
-Clinical Prediction Rule: (1/5 = unlikely, 3/5 = +LR of 30.9, 4/5 = +LR of infinity)
        Gait deviation
        Hoffmann's Sign
        Inverted Supinator Sign (flexion of the fingers)
        Babinski Sign
        Patient age >45 years old

Upper Cervical Instability

Symptoms: myelopathic from cord compression (lump in throat, radiating, paresthesia, balance deficits, coordination deficits, increased reflexes, difficulty walking

Physical Examination
-Special Tests: 
Modified Sharp Purser Test
Alar Ligament Stability Test
Lateral Shift Test
Upper Cervical Flexion Test
Tectoral Membrane Test
Looking for myelopathic symptoms.

Outcome Measures
-NDI
-PSFS

Neck Pain with Mobility Deficits (M54.2 - Cervicalgia)

Symptoms
Central and/or unilateral neck pain, limitations of neck motion that consistently reproduces symptoms, associated (referred) shoulder girdle or upper extremity pain may be present.

Physical Examination
-Limited cervical range of motion
-Neck pain reproduced at end ranges of active and passive motions
-Restricted cervical and thoracic segmental mobility
-Intersegmental mobility testing reveals characteristic restriction
-Neck and referred pain reproduced with provocation of the involved cervical or upper thoracic segments or cervical musculature
-Deficits in cervicoscapulothoracic strength and motor control may be present in individuals with subacute or chronic neck pain

Interventions (Acute)
-Thoracic manipulation
-Cervical mobilization or manipulation.
-Cervical ROM, stretching, and isometric strengthening exercise.
-Advice to stay active plus home cervical ROM and isometric exercise.
-Supervised exercise, including cervicoscapulothoracic and upper extremity stretching, strengthening, and endurance training.
-General fitness training (stay active)

Interventions (Subacute)
-Cervical mobilization or manipulation.
-Thoracic manipulation
-Cervicoscapulothoracic endurance exercise

Interventions (Chronic)
-Thoracic manipulation.
-Cervical mobilization.
-Combined cervicoscapulothoracic exercise plus mobilization or manipulation.
-Mixed exercise for cervicoscapulothoracic regions- neuromuscular exercise: coordination, proprioception, and postural training; Stretching; Strengthening; Endurance training; Aerobic conditioning; And cognitive affective elements.
-Supervised individualized exercises.
-"Stay active" lifestyle approaches.
-Modalities.

Neck Pain with Radiating Pain (M47.2 - spondylosis with radiculopathy, M50.1 - cervical disc disorder with radiculopathy)

Symptoms
neck pain with radiating (narrow band of lancinating) pain in the involved extremity, upper extremity dermatomal paresthesia or numbness, and myotomal muscle weakness.

Physical Examination
-Neck and neck-related radiating pain reproduced or relieved with radiculopathy testing: positive test cluster includes upper-limb nerve mobility, Spurling's test, cervical distraction, cervical ROM
-May have upper extremity sensory, strength, or reflex deficits associated with the involved nerve roots

Interventions (Acute)
-Exercise: mobilizing and stabilizing elements
-Low-level laser
-Possible short-term collar use

Interventions (Chronic)
-Combined exercise: stretching and strengthening elements plus manual therapy for cervical and thoracic region: mobilization or manipulation.
-Education counseling to encourage participation in occupational and exercise activity.
-Intermittent traction. 

Neck Pain with Headache (Cervicogenic) (R51 - headache, M53.0 - cervicocranial syndrome)

Symptoms
Noncontinuous, unilateral neck pain and associated (referred) headache, headache is precipitated or aggravated by neck movements or sustained positions/postures.

Physical Examination
-Positive cervical flexion-rotation test
-Headache reproduced with provocation of the involved upper cervical segments
-Limited cervical range of motion
-Restricted upper cervical segmental mobility
-Strength, endurance, and coordination deficits of the neck muscles

Interventions (Acute)
-Exercise: C1-C2 self-SNAG

Interventions (Subacute)
-Cervical manipulation and mobilization
-Exercise: C1-C2 self-SNAG

Interventions (Chronic)
-Cervical and thoracic manipulation.
-Exercise for cervical and scapulothoracic region: strengthening and endurance exercise with neuromuscular training, including motor control and biofeedback elements.
-Combined manual therapy (mobilization and manipulation) plus exercise (stretching, strengthening, and endurance training elements)

Neck Pain with Movement Coordination Impairment (WAD) (S13.4 - sprain and strain of cervical spine)

Symptoms
Mechanism or onset linked to trauma or whiplash, associated (referred) shoulder girdle or upper extremity pain, associated varied nonspecific concussive signs and symptoms, dizziness/nausea, headache, concentration or memory difficulties, confusion, hypersensitivity to thermal, mechanical, acoustic, odor, or light stimuli.

Physical Examination
-Positive cranial cervical flexion test
-Positive neck flexor muscle endurance test
-Positive pressure our algometry
-Strength and endurance deficits of the neck muscles
-Neck pain with mid-range motion that worsens with end-range positions
-Point tenderness may include myofascial trigger points
-Sensory motor impairments may include altered muscle activation patterns, proprioceptive deficits, postural balance or control
-Neck and referred pain reproduced by provocation of the involved cervical segments

Interventions (Acute if prognosis is for a quick and early recovery)
-Education: advice to remain active, act as usual.
-Home exercise: pain-free cervical ROM and postural element.
-Monitor for acceptable progress.
-Minimize collar use.

Interventions (Subacute if prognosis is for a prolonged recovery trajectory)
-Education: activation and counseling. Combined exercise: active cervical ROM and isometric low-load strengthening plus manual therapy (cervical mobilization or manipulation) plus physical agents: ice, heat, electrical stimulation.
-Supervised exercise: active cervical ROM or stretching, strengthening, endurance, neuromuscular exercise including postural, coordination, and stabilization elements

Interventions (Chronic)
-Education: prognosis, encouragement, reassurance, pain management.
-Cervical mobilization plus individualized progressive exercise: low-load cervicoscapulothoracic strengthening, endurance, flexibility, functional training using cognitive behavioral therapy principles, vestibular rehabilitation, eye-head-neck coordination, and neuromuscular coordination elements
-TENS

Post Surgical Cervical Discectomy and Fusion

Follow surgical precautions (heavy lifting and reaching above shoulder level). Radiograph is ordered and if bone mineralization to lamellar bone is a marker for when formal PT can start. The remodeling phase for bone can last up to a year. The surgeon will need to indicate that the fusion is stable before directly strengthening or stretching the muscles that connect to the cervical spine.

Weeks 4-8
Common postural presentation for this population: increased thoracic kyphosis, increased mid-cervical lordosis, increased upper cervical extension with protraction of the scapula. With this presentation, the weak muscles would be: rhomboids, middle and lower trapezius, deep neck flexors, supraspinatus, infraspinatus, and deltoids. Shortened muscles: pectoralis major and minor, levator scapulae, upper trapezius, scalenes, subscapularis, and sternocleidomastoid. Strengthening of the upper extremities will still need to be performed below 90 degree shoulder elevation until precautions are lifted. Care should be taken with thoracic spine mobilization as mobilization of one segment can cause mobility up to 8 segments away. Direct mobilization of cervical segments should be avoided. Neural gliding techniques are important to prevent adhesion of nerve roots. Assessment of neural mobility and appropriate gliding techniques should be implemented as well as an HEP. Gliding techniques only with minimal neck motion (instead perform wrist flexion/extension with elbow flexion/extension as flossing).

Weeks 9-12
Strengthen cervical spine musculature, cervical biomechanics with UE movement (can initiate UE exercises above 90 degrees at this stage), scapulothoracic mechanics, cervical AROM, and cardiovascular endurance. Cervical isometrics in all planes can begin against the patient's own hand as long as patient can maintain neutral spine while performing. UE exercises above shoulder height can be performed. 
Understand that if pain and fatigue are still a limiting factor, you may have to return to the previous phase until appropriate to progress. 

Weeks 13-52
Regain pre-surgical strength and endurance, sport/work specific activity training, and HEP for discharge.

Outcomes
pVAS, NDI, AROM, UE MMT 

Post-Surgical

Google protocol if physician hasn't implemented. With fusion, no PROM (specifically no stretching) in first 30 days. Implement scapular and shoulder exercises: shoulder rolls, scap retraction and protraction, etc.

Post Surgical Anterior Cervical Discectomy and Fusion

Follow surgical precautions (heavy lifting and reaching above shoulder level). Radiograph is ordered and if bone mineralization to lamellar bone is a marker for when formal PT can start. The remodeling phase for bone can last up to a year. The surgeon will need to indicate that the fusion is stable before directly strengthening or stretching the muscles that connect to the cervical spine.

Weeks 4-8
Common postural presentation for this population: increased thoracic kyphosis, increased mid-cervical lordosis, increased upper cervical extension with protraction of the scapula. With this presentation, the weak muscles would be: rhomboids, middle and lower trapezius, deep neck flexors, supraspinatus, infraspinatus, and deltoids. Shortened muscles: pectoralis major and minor, levator scapulae, upper trapezius, scalenes, subscapularis, and sternocleidomastoid. Strengthening of the upper extremities will still need to be performed below 90 degree shoulder elevation until precautions are lifted. Care should be taken with thoracic spine mobilization as mobilization of one segment can cause mobility up to 8 segments away. Direct mobilization of any cervical segments should be avoided. Neural gliding techniques are important to prevent adhesion of nerve roots (gliders and NOT tensioners). Assessment of neural mobility and appropriate gliding techniques should be implemented as well as an HEP. Gliding techniques only with minimal neck motion (instead perform wrist flexion/extension with elbow flexion/extension as flossing).

Weeks 9-12
Strengthen cervical spine musculature, cervical biomechanics with UE movement (can initiate UE exercises above 90 degrees at this stage), scapulothoracic mechanics, cervical AROM, and cardiovascular endurance. Cervical isometrics in all planes can begin against the patient's own hand as long as patient can maintain neutral spine while performing. UE exercises above shoulder height can be performed. 
Understand that if pain and fatigue are still a limiting factor, you may have to return to the previous phase until appropriate to progress. 

Weeks 13-52
Regain pre-surgical strength and endurance, sport/work specific activity training, and HEP for discharge.

Outcomes
pVAS, NDI, AROM, UE MMT 

Protocols: https://wexnermedical.osu.edu/neurological-institute/clinical-centers/ohio-state-spine-care/spine-rehabilitation-guidelines