Neck Assessment

In this chapter you will find lots of tips on how to assess someone who comes to you with a neck complaint. This might be something as simple as a stiff neck, a sore neck, feeling tense after sitting for long periods of time at work, or perhaps even an odd “niggle” in the neck caused by an injury that happened many years ago. It could be someone you have been treating for many months or a new client.

The tips and tricks you will find here are not arranged in any particular order. The information here is not designed to replace any training you have had. Instead, it is designed to support and enhance your existing skills and is crammed with the kinds of tips you may not have come across, tips and tricks I have picked up over the years, and which I hope you too will find beneficial in your practice. Of course, there will be material with which you are familiar, but I am hoping that you will discover a selection of assessment tips which make you think, “Ah, I haven’t tried that, maybe that will work!”

Most therapists reading this book will be sensible enough to know that you would not carry out any of these assessments on a person with an acute injury to their neck, such as whiplash. You will find only a few cautions written into the text in this chapter, and the reason is that the majority of these assessments are perfectly safe for the majority of people you are likely to be assessing. Where special caution is needed, this has been stated, so please read the whole tip before attempting the assessment.

When a client comes to you with a neck problem, one of the simplest assessments you can make—once you have finished asking questions—is to observe which movements they can (and cannot) perform with their neck. You may already be doing this and may know that this is called a range of movement (ROM) test. Because you are going to ask the client to perform the movements themselves, this is an active ROM test. You may have heard of passive ROM tests, where the therapist takes a joint through its ROM, but in this section, for this part of the body, we are only going to do active ROM tests.

The neck can move in six ranges for the purposes of this assessment: flexion/extension, right lateral flexion/left lateral flexion, and right rotation/left rotation.

A good place to start when assessing the neck is to demonstrate to your client what it is you want them to do, and then to watch how they perform the movements and to note what they say.

Question: Does it matter where you stand when carrying out this assessment?

Question: When caution is needed, what instructions might you give the client prior to them performing the test?

Use the table on the opposite page to help you record five neck assessments. The illustrations at the top of the table are a reminder of the six movements you need to check. One assessment has been filled in for you, for a subject called Mrs. Brown, aged 64. From the table you can see that she has 30 degrees of flexion and 20 degrees of extension; 30 degrees of right rotation and 25 degrees of left rotation; and 10 degrees of right lateral flexion and 20 degrees of left lateral flexion.

It would be wrong to say that all elderly people have a reduced ROM in their neck. Some may have an increase in range—maybe they are fitness enthusiasts and include neck stretches in their routines, or perhaps they had increased mobility to start with. You get the idea. So, while we do not want to pigeonhole people, the more people you assess, the more likely you are to be able to identify when a client has a ROM that is greater or less than normal, taking into account their age, occupation, lifestyle, and health factors.

The problem with measuring ROM is that people’s necks can “hinge” in different places. That is, some of the vertebrae can remain “stuck,” while others move more freely, so the movement we observe is not coming equally from each of the seven cervical vertebrae. Vertebrae do not form hinge joints, as you know, but the movement impairment that is sometimes observed when people perform ROM assessments may be thought of as a hinging movement.

If you want to be more accurate in your cervical ROM measurement, you could use a goniometer. Begin with your client seated, preferably with their back supported and feet flat on the floor. Then, position your goniometer as shown in this tip and measure the different ranges. Follow the instructions provided on the following pages to help you to measure flexion, extension, lateral flexion, and rotation.

1. Position the center of your goniometer over the external auditory meatus.

2. Ensure that the arm of the goniometer that is to be stationary is perpendicular to the floor.

3. Align the arm of the goniometer that is to move with nares.

4. Ask your client to take their chin as close to their chest as possible and, as they do this, move the arm of the goniometer to keep it aligned with nares. Be sure to keep the stationary arm of the goniometer fixed. Take your measurement.

1. Position the center of your goniometer over the external auditory meatus.

2. Ensure that the arm of the goniometer that is to be stationary is perpendicular to the floor.

3. Align the arm of the goniometer that is to move with nares.

4. Ask your client to take their head as far back as possible, trying to get the back of their head to touch the top of their back. As the client does this, move the arm of the goniometer you have aligned with nares. Be sure to keep the stationary arm of the goniometer fixed. Take your measurement.

1. Locate the spinous process of C7.

2. Locate the occipital protuberance and spinous processes of thoracic vertebrae.

3. Position the center of your goniometer over C7, with the stationary arm over the spinous processes of thoracic vertebrae and the moveable arm over the occipital protuberance.

4. Instruct your client to keep their shoulders still and down as they move their head to try and get their ear to touch the shoulder on that side. Keep the moving arm in alignment with the occipital protuberance and take your measurement at the end of range. Repeat this on the opposite side.

Lateral flexion can also be measured using a goniometer as the therapist stands in front of the client.

1. Start by asking your subject to hold a tongue depressor between their teeth. These are inexpensive and may be obtained from many pharmacies.

2. Position the goniometer parallel to the tongue depressor.

3. Ask your client to take their ear to their shoulder on the side at which you are holding the goniometer. Move the goniometer as they do this, keeping it parallel with the tongue depressor. Measure the number of degrees of lateral flexion when they reach the end of their active ROM.

1. Locate the very top of the head and the acromion process.

2. Position the center of your goniometer over the center of the head and the stationary arm over the acromion process. Position the moving arm of your goniometer over the tip of the nose.

3. Ask your client to try and keep their chest and shoulder still as they turn their head to look over one shoulder. Move the stationary arm of the goniometer as they do this, keeping it aligned with the nose. At the end of range, take your measurement. Repeat on the other side.

Flexion

Measure the distance from the chin to the sternal notch.

Extension

Measure the distance from the chin to the sternal notch.

Lateral Flexion

Measure the distance from the mastoid process to the acromion process

Rotation

Place a mark on your client’s acromion process. Measure the distance from the tip of the chin to the acromion process (on the side to which the client rotates).

Let us take the example of a client who comes to you with a stiff neck. You assess them, asking them to do the active ROM test, and then you decide on an appropriate treatment. Assuming that the goal of your treatment is to decrease their feelings of stiffness and/or increase their actual active movement, you will need to document the client’s current limitation in ROM, as well as their posttreatment increase in ROM. Here are some ideas.

• One way to do this is to make a little sketch. It could be a small oval to represent a head, like the cartoons shown here.

• Or, it could be a line, either superimposed over the sketch or simply on its own.

• Or, you could guesstimate in degrees the amount by which the range is decreased. For example, if rotation was decreased by what you thought was 5 degrees you could write –5 degrees with a line representing rotation.

Experiment with different ways to document ROM findings until you find those that you are comfortable with and, importantly, which you will understand when you refer to your notes in the future.

Sometimes a client is able to perform full ROM, yet the quality of their movement is poor. Maybe they wince or grimace as they perform the movement (another good reason to face your client when you carry out ROM tests) and yet are still able to perform it fully. Maybe they stop and start, taking their neck through its full range but with hesitancy. Or perhaps you simply get a sense of their caution, that they are guarding themselves. Hesitancy may be common following whiplash injuries, for example, when the tissues are healed, but the client is fearful of reinjury. A client with an inability to perform active cervical ROM fluidly could be described as having a “poverty” of movement. It is as important to document the quality with which a movement may be performed as it is to document the ROM attained, as this provides yet another piece of your assessment puzzle.

As with your documentation of the actual ROM, you will need to find a way to record the quality of movement in a way that you understand. “Poverty,” “hesitancy,” “guarding?,” etc., could be useful. Notice that there is a question mark after “guarding.” This is deliberate because we cannot know as a therapist whether someone is guarding themselves when they move their neck, as this is a subjective assessment of the movement we have observed.

Question: What might you record if you observe a client to have full range of active neck movement, yet in order to perform the movements the client keeps wincing?

Many clients visit a therapist hoping to get relief from discomfort in their neck. If you are reading this as an experienced therapist, you will know that the words clients use to describe how they are feeling do not always involve the word “pain.” Have you ever come across someone who says that their neck is “pulling,” “tight,” or that it “clicks”? Or someone who says they have a “sore” neck or that it is “a bit crunchy”? Can you remember whether you repeated the words used by the client, or whether, in response, you said something like, “So whereabouts is the pain?” It can be a challenge to avoid using the word “pain.” It is a word bandied about, used to embrace a plethora of descriptive terms such as those listed above as well as “stiff,” “aching,” and “hurt.” But why should it matter? Why not document your client’s problem using the word “pain” as a generally descriptive term? Accurate documentation is important for several reasons. First, because if we use a patient’s description of their symptoms as a baseline measurement against which we judge the effectiveness of our treatment, then it is important we do this accurately. “Pulling” or “crunching,” for example, are descriptions of sensations which we are likely to want to lessen. If, following the treatment of a client with such symptoms, we ask them, “Has your pain diminished?” the answer will be meaningless. What we need to be asking is whether their “pulling” or “crunching” sensation has diminished.

Another important reason for using and documenting what clients say is that by doing so people feel that they are being “heard.” This alone increases the chances of building rapport between the client and the clinician. A third reason for accurate recording of terms used is that this prevents the assessment water from getting muddied. If you start using the word “pain” too often to describe a client’s symptoms, sooner or later the client will start using the word. This can lead to misdiagnosis and inappropriate treatment.

This next test is simple and rather crude but may help determine whether a neck problem is purely muscular, or whether there is an underlying skeletal/ligamentous component. It is a useful test because if you suspect that a client’s problem may be due to the cervical vertebrae themselves, or due to the ligaments of these joints, it means that you are in a good position to refer your client to a physiotherapist, an osteopath, or a chiropractor for further investigation if the specific assessment of joints is outside your professional remit.

Passively elevating the shoulders takes some tension out of the muscles spanning the shoulder–neck region and reduces the pull on their connecting fascia. Therefore, if with passive elevation of the shoulders, pain/stiffness/discomfort is reduced, and ROM is increased, there is a strong likelihood that muscles such as upper trapezius, levator scapulae, or rhomboid minor are contributing to the client’s problem. These muscles or their surrounding fascia, or both may be shortened.