Testing the Muscles of the Neck

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

FIGURE 3-1

FIGURE 3-2

Range of Motion

Table 3-1

CAPITAL EXTENSION

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 nuchae C7-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 Patient:

Prone with head off end of table. Arms at sides.

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.

FIGURE 3-3

Test:

Patient extends head by tilting chin upward in a nodding motion. (Cervical spine is not extended.)

Instructions to Patient:

“Look at the wall. Hold it. Don’t let me tilt your head down.”

Grading

Grade 5 (Normal):

Patient completes available range of motion without substituting cervical extension. Tolerates maximum resistance. (This is a strong muscle group.)

Grade 4 (Good):

Patient completes available range of motion without substituting cervical extension. Tolerates strong to moderate resistance.

Grade 3 (Fair)

Position of Patient:

Prone with head off end of table and supported by therapist. Arms at sides.

Position of Therapist:

Standing at side of patient’s head. One hand should remain under the head to catch it should the muscles fail to hold position (Figure 3-4).

FIGURE 3-4

Instructions to Patient:

“Look at the wall.”

Test:

Patient completes available range of motion with no resistance.

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.

FIGURE 3-5

Test:

Patient attempts to look back toward therapist without lifting the head from the table.

Instructions to Patient:

“Tilt your chin up,” OR “Look back at me. Don’t lift your head.”

Grading

Grade 2 (Poor):

Patient completes limited range of motion.

Grade 1 (Trace) and Grade 0 (Zero):

Palpation of the capital extensors at the base of the occiput just lateral to the spine may be difficult; the splenius capitis lies most lateral and the recti lie just next to the spinous process.

Helpful Hints

• Clinicians are reminded that the head is a very heavy object suspended on thin support. Whenever testing with the patient’s head off the table, extreme caution should be used for the patient’s safety, especially in the presence of suspected or known neck or trunk weakness. Always place a hand under the head to catch it should the muscles give way.

• Significant weakness of the capital extensor muscles combined with laryngeal and pharyngeal weakness can result in a nonpatent airway. There also may be inability to swallow. Both of these problems occur because the loss of capital extensors leaves the capital flexors unopposed, and the resultant head position favors the chin tucked on the chest, especially in the supine position.¹ This problem is not limited to patients with severe polio paralysis; it is also evident in patients with severe rheumatoid arthritis. Patients with chronic forward head posture also commonly have weak cervical extensors.

PLATE 1

Cervical Extension

FIGURE 3-6

FIGURE 3-7

Range of Motion

0° to less than 30°

Table 3-2

CERVICAL EXTENSION

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 nuchae T1-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 Patient:

Prone with head off end of table. Arms at sides.

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.

FIGURE 3-8

Test:

Patient extends neck without tilting chin.

Instructions to Patient:

“Push up on my hand but keep looking at the floor. Hold it. Don’t let me push it down.”

Grading

Grade 5 (Normal):

Patient completes full range of motion and holds against maximum resistance. Therapist must use clinical caution because these muscles are not strong, and their maximum effort will not tolerate much resistance.

Grade 4 (Good):

Patient completes full range of motion against moderate resistance.

Grade 3 (Fair)

Position of Patient:

Prone with head off end of table. Arms at sides.

Position of Therapist:

Standing next to patient’s head with one hand supporting (or ready to support) the forehead (Figure 3-9).

FIGURE 3-9

Test:

Patient extends neck without looking up or tilting chin.

Instructions to Patient:

“Lift your forehead from my hand and keep looking at the floor.”

Grading

Grade 3 (Fair):

Patient completes range of motion but takes no resistance.

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).

FIGURE 3-10

Grade 2 (Poor), Grade 1 (Trace), and Grade 0 (Zero)

Position of Patient:

Supine with head fully supported by table. Arms at sides.

Position of Therapist:

Standing at head end of table facing the patient. Both hands are placed under the head. Fingers are distal to the occiput at the level of the cervical vertebrae for palpation (Figure 3-11).

FIGURE 3-11

Test:

Patient attempts to extend neck into table.

Instructions to Patient:

“Try to push your head down into my hands.”

Grading

Grade 2 (Poor):

Patient moves through small range of neck extension by pushing into therapist’s hands.

Grade 1 (Trace):

Contractile activity palpated in cervical extensors.

Grade 0 (Zero):

No palpable muscle activity.

Combined Neck Extension

(Capital plus Cervical)

Range of Motion

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Tags: Daniels and Worthinghams Muscle Testing Techniques of Manual

Aug 25, 2016 | Posted by admin in RHEUMATOLOGY | Comments Off

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