Clinical Examination

Clinical Cornerstone:

• It’s important to view the patient holistically, considering the biopsychosocial aspects of the patient’s condition. When re-evaluating existing patients, a thorough assessment is just as important.

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Useful for arriving at a diagnosis:

• Observations: Abnormalities, asymmetries, posture, balance, gait, movements, facial expression.

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• Red Flags: Examination of complaints that might indicate a more serious underlying condition (see 'Red Flags' Section).

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• Neurological Examination:

  • Motor Strength: Test the strength of the upper and lower extremities.

  • Sensory Examination: Check for any sensory deficits in the upper and lower extremities.

  • Reflexes: Test the biceps, triceps, brachioradialis reflexes and the patellar and Achilles reflexes.

  • Cranial Nerves: Test CN sensation (e.g. facial numbness), CN motor (e.g. smile, tongue deviation, H-pattern, saccades, shoulder shrug), and CN reflexes (e.g. pupillary light, corneal, gag) as indicated.

  • UMN (upper motor neuron) Testing: If cervical myelopathy is a clinical consideration, tests such as Hoffman’s, Inverted Supinator Sign, and Romberg’s can be informative.

  • Balance: Romberg’s (static balance), Tandem gait (dynamic balance)

  • Cerebellum: e.g. Heel-shin, Finger-nose, Diadokinesia

  • Cognitive: 10 word immediate recall, Digit string backwards test, Delayed word recall

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• Vitals: Blood pressure and heart rate (taken in two positions: supine, standing).

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• Special/Orthopedic Tests: In the absence of red flags, select tests to use alongside a fulsome clinical examination, since the specificity and sensitivity of these tests vary. Tests selection should consider the presenting condition. Examples include: Rotary-chair test, Head Impulse test, Vestibulo-occular Reflex (VOR) test, additional Vestibular Occulomotor screening (VOMS) (e.g. Smooth pursuit, Saccades, Vestibulo-occular Cancellation test, Accomodation, Convergence), and Dynamic Visual Acuity (DVA) test.

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• Imaging/laboratory tests: As indicated (e.g., red flags are present, progressive neurological deficits, non-response to care).

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May help guide treatment:

• Palpation: Palpate bony and muscular areas of the cervical spine.

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• Movement: Active ROM in all planes (flexion, extension, lateral flexion, and rotation). Passive ROM. Consider regional and segmental hypomobility, hypermobility and aberrant movement patterns.

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• Associated Special/Orthopedic Tests: In the absence of red flags, select tests to use alongside a fulsome clinical examination, since the specificity and sensitivity of these tests vary. Tests selection should consider associated conditions and the differential diagnoses from the History. Examples include: Spurling’s test, Neck Distraction test, Cervical Kemps, Spinous Percussion, and Bakody’s sign.

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Documentation: Record all findings in the patient record.