Testing the Muscles of the Neck
Note: This section of the book on testing the neck muscles is divided into tests for capital and cervical extension and flexion and their combination. This distinction was first described by Perry and Nickel as a necessary and effective way of managing nuchal weakness or paralysis.1 All muscles acting on the head are inserted on the skull. Those muscles that lie behind the coronal midline are termed capital extensors. Motion is centered at the atlanto-occipital and atlantoaxial joints.2,3
Capital Extension


Table 3-1
I.D. | Muscle | Origin | Insertion |
56 | Rectus capitis posterior major | Axis (spinous process) | Occiput (inferior nuchal line laterally) |
57 | Rectus capitis posterior minor | Atlas (tubercle of posterior arch) | Occiput (inferior nuchal line medially) |
60 | Longissimus capitis | T1-T5 vertebrae (transverse processes)C4-C7 vertebrae (articular processes) | Temporal bone (mastoid process, posterior surface) |
58 | Obliquus capitis superior | Atlas (transverse process) | Occiput (between superior and inferior nuchal lines) |
59 | Obliquus capitis inferior | Axis (lamina and spinous process) | Atlas (transverse process, inferior-posterior surface) |
61 | Splenius capitis | Ligamentum nuchaeC7-T4 vertebrae (spinous processes) | Temporal bone (mastoid process)Occiput (below superior nuchal line) |
62 | Semispinalis capitis (distinct medial part often named Spinalis capitis) | C7-T6 vertebrae (transverse processes)C4-C6 vertebrae (articular processes) | Occiput (between superior and inferior nuchal lines) |
124 | Trapezius (upper) | Occiput (external protuberance and superior nuchal line, middle 1/3)C7 (spinous process)Ligamentum nuchae | Clavicle (posterior border of lateral 1/3) |
63 | Spinalis capitis | Medial part of Semispinalis capitis, usually blended inseparably | Occiput (between superior and inferior nuchal lines) |
Other | |||
83 | Sternocleidomastoid (posterior) |
Grade 5 (Normal) and Grade 4 (Good)
Position of Therapist:
Standing at side of patient next to the head. One hand provides resistance over the occiput (Figure 3-3). The other hand is placed beneath the overhanging head, prepared to support the head should it give way with resistance, which is applied directly opposite to the movement of the head.

Grade 2 (Poor), Grade 1 (Trace), and Grade 0 (Zero)
Position of Patient:
Supine with head on table. Arms at sides. Note: The gravity minimized position (side-lying) is not recommended for any of the tests of the neck for grades 2 (Poor) and below because test artifacts are created by the therapist in attempting to support the head without providing assistance to the motion.
Position of Therapist:
Standing at end of table facing patient. Head is supported with two hands under the occiput. Fingers should be placed just at the base of the occiput lateral to the vertebral column to attempt to palpate the capital extensors (Figure 3-5). Head may be slightly lifted off table to reduce friction.

Cervical Extension


Table 3-2
I.D. | Muscle | Origin | Insertion |
64 | Longissimus cervicis | T1-T5 vertebrae (transverse processes) variable | C2-C6 vertebrae (transverse processes) |
65 | Semispinalis cervicis | T1-T5 vertebrae (transverse processes) | Axis (C2)-C5 vertebrae (spinous processes) |
66 | Iliocostalis cervicis | Ribs 3-6 (angles) | C4-C6 vertebrae (transverse processes, posterior tubercles) |
67 | Splenius cervicis (may be absent or variable) | T3-T6 vertebrae (spinous processes) | C1-C3 vertebrae (transverse processes) |
124 | Trapezius (upper) | Occiput (protuberance and superior nuchal line, middle 1/3)C7 (spinous process)Ligamentum nuchae T1-T12 vertebrae occasionally | Clavicle (posterior border of lateral 1/3) |
68 | Spinalis cervicis (often absent) | C7 and often C6 vertebrae (spinous processes)Ligamentum nuchaeT1-T2 vertebrae occasionally | Axis (spinous process)C2-C3 vertebrae (spinous processes) |
Others | |||
69 | Interspinales cervicis | ||
70 | Intertransversarii cervicis | ||
71 | Rotatores cervicis | ||
94 | Multifidi | ||
127 | Levator scapulae |
The cervical extensor muscles are limited to those that act only on the cervical spine with motion centered in the lower cervical spine.2,3
Grade 5 (Normal) and Grade 4 (Good)
Position of Therapist:
Standing next to patient’s head. One hand is placed over the parieto-occipital area for resistance (Figure 3-8). The other hand is placed below the chin, ready to catch the head if it gives way suddenly during resistance.

Grade 3 (Fair)
Grading
Alternate Test for Grade 3:
This test should be used if there is known or suspected trunk extensor weakness. The therapist should always have an assistant participate to provide protective guarding under the patient’s forehead. This test is identical to the preceding Grade 3 test except that stabilization is provided by the therapist if needed to accommodate trunk weakness. Stabilization is provided to the upper back by the forearm placed over the upper back with the hand cupped over the shoulder (Figure 3-10).


Full access? Get Clinical Tree

