Neck Assessment

Chapter I

Neck Assessment

Chapter 1 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.

Tip 1: Assessing Range of Movement

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 which movement the client performs first?

No. If you are new to this form of assessment, one tip is always to perform the movements in the same order, with every client. For example, flexion, then extension and back to neutral; right rotation, then left rotation and back to neutral; right lateral flexion, then left lateral flexion and back to neutral. That way, you are unlikely to miss anything. However, there may be times when you need to make an exception. For example, if a client has already told you that they experience discomfort on a particular movement—rotation of their head to the right, for example—it is sometimes a good idea to ask them to perform this particular movement last. The reason for this is that if the client experiences discomfort at the start of the assessment, they may be less willing to continue and you may not discover which movements they can and cannot make. So, if a client tells you that they experience discomfort on looking over their right shoulder when trying to reverse their car, make right rotation the last ROM that you test, checking the other five movements first.

TIP: Make sure that your client does not move their shoulders when performing ROM tests. Clients with neck pain or a stiff neck have a tendency to twist at the waist and move their thorax in order to rotate to the right or to the left, instead of rotating their neck. Similarly, when asked to perform lateral flexion, they have a tendency to raise their shoulders: if lateral flexion to the right is uncomfortable or difficult, they raise their left shoulder, thus appearing to be able to move in this direction when in fact the movement is generated from their torso. Check for these “cheating” movements by paying close attention to your client’s shoulders during the test. If you see movement in the shoulders, instruct your client to start again, while keeping their shoulders stationary. By asking the client to keep their shoulders stationary, the limitations in their cervical ROM become more apparent and you therefore get a more accurate picture of what they can and cannot do with their neck.

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

Some therapists stand behind their clients when assessing active cervical ROM. The advantage is that the therapist can observe the cervical spine. The disadvantage is that the client may feel anxious having someone stand behind them, even though the cervical ROM test is quick to perform: as you know, people are protective of their necks, more so if they are in pain or have suffered neck problems in the past. Standing in front of your client, you have the advantage of being able to observe their facial expressions. This position is also more conducive to the development of rapport.

Question: Are active ROM tests safe for all clients?

Active ROM tests are safe for most people because everyone moves their head through these ranges—and combinations of these ranges—during the day. Active ROM tests may not be safe in certain, very specific, circumstances: following an accident or following surgery to the neck, for example. This section is not designed to help you assess people with cervical trauma. Also, there may be a small group of people for whom caution is needed when asking them to perform active movements involving the head and the neck. For example, active ROM tests should be performed with caution if, when taking the client’s medical history, you discover your subject suffers from an inner ear disorder such as Ménière’s disease. Another example is if they report experiencing dizziness when they look up to the ceiling.

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

Instruct them to move their head slowly or to stop if they feel in any way dizzy or unwell.

Tip 2: How to Tell What Is a “Normal” Range of Movement

So you have tested your client’s active cervical ROM. As they were performing the movements you found yourself asking, “How do I know what is a ‘normal’ ROM in the neck?” Well, there are many books in which normal ranges of movement can be found. One such book is The Clinical Measurement of Joint Motion by the American Academy of Orthopaedic Surgeons (Green and Heckman 1994). This has clear illustrations and focuses only on this topic, so it is easy to follow.

However, a good tip is simply to assess a lot of people. By doing this you will soon get to build up a kind of visual database, a set of images in your mind as to what is normal and what is not. When you see someone who can only flex their head to the side a little, you will know that they have a ROM less than the norm. Conversely, when a client effortlessly bends their head to the side so that their ear appears to almost touch their shoulder, you will know that they have a ROM greater than the norm.


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.

Question: What if a client reports a problem involving movement, yet when you test them, they appear to have a normal ROM? That is, flexion, extension, lateral flexion (both left and right), and rotation (both left and right) all appear fine, with little or minimal discomfort.

There are many factors contributing to neck discomfort (movement is one of them). The thing to remember is that in daily life we combine these movements. For example, if you are holding this text slightly lower than horizontal in order to read it, your neck may be a little flexed. If you were to keep your neck flexed but look over your right shoulder, you are now combining forward flexion with right rotation. Similarly, if you look up into the sky and trace the path of an aircraft as it passes overhead, your neck is in extension and will involve a degree of rotation, depending on which way the aircraft is moving. Try rubbing your left ear on your left shoulder by moving your head. You are now combining left lateral flexion with both right and left rotation. So, it may be that a client’s condition is aggravated not by one movement, but by a combination of movements, and this is worth remembering as it provides further clues that will help you determine what the problem, and the appropriate treatment, might be.

Tip 3: Using a Goniometer to Measure Cervical ROM

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.


Questions to ask yourself:

How easy did I find using a goniometer to measure cervical ROM?

Did I find any particular aspects easier than others? For example, was it easier for me to measure rotation than lateral flexion?

What could I do differently next time to improve my skill in using a goniometer to measure cervical ROM?

Would using a larger or smaller goniometer help?

Was the client positioned correctly? Could I change the position in any way to make measuring easier or more accurate?

How good was I at giving instructions to my subject? Did they understand? Is there anything I need to do differently next time?

How easy was it for me to record my findings?

Questions to ask about your client:

How do their ROM measurements compare with other subjects of their age and gender?

Are there differences in left- and right-sided readings?

Have these measurements changed over time and if so, in what way?

In what way might a ROM finding relate to my client’s daily life—does decreased (or increased) ROM make any daily tasks more difficult?

Would helping to alter ROM improve my client’s quality of life in any way? For example, if they had greater cervical rotation, would that help when they are looking over their shoulder to reverse their car?

How might I explain ROM findings to my client in a way that is reassuring?

Measuring Neck Flexion with a Goniometer

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.


Measuring Neck Extension with a Goniometer

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.


Measuring Lateral Flexion of the Neck with a Goniometer

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.


Alternative Method of Measuring Lateral Flexion

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.


Measuring Neck Rotation with a Goniometer

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.


Document your findings

Note the date.

Note the position of your client during the ROM tests.

Note what equipment you used.

Record your measurements.

For example

• Flexion 50%

• Extension 10%

• Right rotation 20%

• Left rotation 30%

• Right lateral flexion 25%

• Left lateral flexion 30%

Record anything else you think was significant.

For example, “client was unable to rotate to the right without shrugging the right shoulder.”

Tip 4: Using a Tape Measure to Measure Cervical ROM


Measure the distance from the chin to the sternal notch.



Measure the distance from the chin to the sternal notch.


Lateral Flexion

Measure the distance from the mastoid process to the acromion process



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).


Tip 5: Documenting Your ROM Findings

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.

Tip 6: Checking Quality of Movement

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?

In documenting your observations, would it be appropriate to write something like:

full movement—? pain

What do you think?

Tip 7: Documenting Discomfort

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.

A final important reason for using the patient’s exact terminology is that people tend to use similar words to describe similar diseases, and so having precise words can help with a more precise diagnosis. For example, and very generally, clients experiencing problems involving nerves might describe their symptoms as “sharp,” “shooting,” or “tingling,” whereas those clients suffering bone or muscle problems might use words such as “deep,” “boring,” or “aching.” Some of the words clients use to describe neck symptoms following whiplash can be very strange indeed, and it is important that as therapists we document whatever words our clients use in order to add to the collective understanding of how such conditions present in the clinical population. This concept is explored in depth in Pain: The Science of Suffering by Patrick Wall (1999).

TIP: A tip for helping you to avoid prompting your clients with use of the word “pain” is to write out some alternative questions. For example:

“Can you elaborate?”

“What sort of discomfort is it?”

“When did you first notice it?” (rather than “When did you first get the pain?”)

“When you say it is uncomfortable, can you be more specific?”

Using these kinds of open-ended questions encourages the client to search for words that best describe their symptoms and can help you discover more about the nature of the problem.

Tip 8: A Differentiation Test

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.

For this test, you will need to stand behind your client, which, as was noted in Tip 1 (p. 6), has certain disadvantages. However, it is necessary for this particular test. This test relies on what your client says, so it is important to listen to the descriptive terms they use.

First, with your client seated, test their ROM by asking them to perform the movements of flexion, extension, lateral flexion, and rotation described in Tip 1 (p. 6). Observe the degree and quality of movement, and ask how the movements feel.

Document these findings. Remember from Tip 7 (p. 22) to identify the exact words the client uses to describe any discomfort, words such as “pulling,” “pinching,” “sticking,” “catching,” or “squashing.”


Second, still standing behind your seated subject, passively elevate their shoulders, supporting them under the elbow. Safeguard your own posture as you do this to avoid straining your back. Maintaining this position of passively elevated shoulders, ask your client to repeat the active cervical ROM, observe their movements, and again get feedback.

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.

Aug 25, 2019 | Posted by in MANUAL THERAPIST | Comments Off on Neck Assessment

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