Cervicothoracic tests

Purpose

The purpose of “Cervicothoracic tests” is to provoke the patient’s symptoms of neck pain. These clinical tests are part of the examination proceeded in order to establish the differential diagnosis[1].

Before performing the clinical test, it is important to get a detailed history of the patient. One shall ask the patient what pain he experiences, where exactly the pain is located, how long he has experienced these symptoms and what causes/provokes the pain.

It is also important to identify whether there exists a relation between complaints in the history of the patient (injuries, accident, ...) and the symptoms he experiences, as well as whether there are red flags or not.

Following the history and the clinical examination, a correct diagnosis can be established and the treatment for the patient can be determined (mechanical or non-mechanical pain[1], acute or chronic pain, ...).

Shoulder abduction test

1. Purpose

Shoulder abduction test is a provocative test for the diagnosis of cervical radiculopathy. Davidson et al. defined the shoulder abduction relief as a sensory indication related with a high occurrence of soft disc protrusion, demonstrating the sensory root or ganglion is straight elevated cephalad or pulled laterally to the upsetting extradural compressive lesion by the maneuver. (In the study, 68% of patients with radicular signs and symptoms noted relief with shoulder abduction.) The test is evaluated as positive if motor weakness, lateral extradural lesions or radicular paresthesias are present. These symptoms indicate the need for surgical treatment. A positive shoulder abduction test is also known as Bakody's sign.
In fact, the mechanism is of the test is to take stretch off of the affected nerve root and this may drop the radicular symptoms.[2]

2. Technique

It is important that the patient has complaints while in rest[3]. The patient is sitting and is instructed to put the hand of the affected extremity on his head. This is done to support the extremity in the scapular plane. A positive response is reduction of ipsilateral cervical radicular symptoms.

[4]

3. Evidence

Sensitivity ranges from 43% up to 50%.
Validity ranges from 80% up to 100%.

This leads us to the conclusion that this test has a high specificity and a low sensitivity for cervical radiculopathy.[5]

4. Recent related research

Significant decrease of pressure was noted by Farmer et al. by taking measurements with a pressure transducer and also a monitor implanted in the neural foramen in cadavers and abducting the shoulder. A likely mechanism for this outcome is a diminution in the tractional forces hired on the brachial plexus by abridging the space between the coracoid and transverse process of the fifth cervical vertebra C5. An alternative likely mechanism is lifting of the dorsal root ganglion cephalad from an extradural compression lesion.[6]
Cox communicates the shoulder abduction as producing or releasing arm pain depending on whether the nerve is compressed medially or laterally by a cervical disc herniation. He also facts how a medial disc will compress the nerve root and is released as the nerve is elevated from the disc by arm abduction. Cox additional specifies that the soreness is made worse if the arm hangs or is tractioned downward. A lateral disc is released when the arm hangs and is worse when the arm is abducted[7]. The thoracic outlet syndrome is known with a painful abduction of the arm. The shoulder abduction relief sign is more expected to be present if there is a soft disc herniation, whereas, the test is credible to be negative with radiculopathy caused by spondylosis.[7]


Stenvers Tests

1. Purpose

(Mechanical) Neck pain can also be caused by a scapular dysfunction. The Stenvers tests are an orienting examination and consist in 5 tests in order to determine the mobility of the shoulder and cervicothoracic region (C7-T4). A positive test gives an indication about a dysfunction in this region, and indicates that more examination (joint and motion examination) is needed.

2. Technique[8]

Each test has to be performed at each side in order to determine the differences between left and right.

I. CT-transition

The arm of the patient is bringing passively in 160° flexion, while the examiner palpates the contralateral side of the vertebrae (from C7 to T4).

During the movement of the arm, the examiner feels the rotation of the vertebrae by an increase of the pressure against the finger from 160°.

When there is a difference between the left and right side and when there is a vertebrae rotation before 160° flexion, the test will be considered positive for a decrease in mobility of the vertebrae.

II. Armpit hairline

The patient is bringing his arm to a maximal flexion, while the examiner is measuring the distance between the inferior angle of the scapula and the armpit hairline.

A distance more than one finger width indicates a decreased mobility of the shoulder.

III. Horizontal adduction
The examiner palpates the lateral margin of the shoulder while the patient is bringing his arm in adduction. In normal circumstances the shoulder does not move before 90° adduction. Otherwise (positive test), the posterior capsule of the shoulder can be shortened.
IV. Clavicular Roll

The examiner places his finger in the supraclavicular fossa. During a flexion movement of the arm, the clavicle moves around the examiner’s finger according a “roll-movement”. If this movement cannot be realised, it means an impaired movement of the shoulder girdle.
V. Tipping out scapula

The patient brings his arm actively in flexion while the examiner is palpating the inferior angle of the scapula.

During the movement, the scapula moves downwards and the inferior angle tips out. When this movement cannot be realized, this means a malfunction of the scapulothoracic sliding surface.

[9]


3. Evidence

No evidence is found.

Adson test

1. Purpose

The Adson test is a technique to assess for evidence of circulatory symptoms caused by the presence of a cervical rib. Reduction in size of the radial pulsation is common; the pulsation can be diminished or abolished by having the patient elevate the chin or rotate the head to the affected side of the body while inhaling. This would be caused by “constriction of the subclavian artery or vein, obstruction of the radial and ulnar arteries by emboli at the site of constriction, or perhaps by disorder of the sympathetic innervation.” They assumed that this evidence of circulatory disturbance justified attention for surgical resection of the cervical rib.

2 Technique

The patient’s head is rotated to face the tested shoulder. The patient then extends his/her head while the assessor laterally rotates and extends the patient’s shoulder. The examiner finds the radial pulsation, and the patient is asked to inhale once very deeply and hold it. A disappearance of the pulsation is indicative of a positive test.”

[10]

3. Evidence

For Adson’s test there are no tentative statements with affection to interexaminer reliability, sensitivity, and specificity, based on the existing literature. The specificity has ranged from 18% up to 87% and the sensitivity has approached 94%[11]


Valsalva Maneuver

1. Purpose

Valsalva maneuver is a provocative test useful for the diagnosis of cervical radiculopathy.

2. Technique
While sitting, the patient is instructed to take a deep breath and hold the breath while attempting to exhale over a 2-3-second period with gradually increasing force. This is basically holding pressure against a closed glottis.

[12]

This maneuver increases intraspinal pressure and may reproduce radicular symptoms because of a narrow neuroforamen due to an extruded intervertebral disc or osteophytes.[13]

3. Evidence
Only one study was found that investigated the sensitivity and specificity of the valsalva manoeuvre. Following results were found:
- Sensitivity : 22%
- Specificity : 94%
Low to moderate sensitivity and high specificity[8]. Further examination is necessary.


Presentations

https://vimeo.com/65773894Cervicothoracic disorders ppt.PNG
Adverse Neural Dynamics Related to Cervicothoracic Disorders and Symptoms

This presentation, created by Damian Rodriguez, Allison Rose, David Self, Blake Spoon; Texas State DPT Class.

View the presentation

References

  1. 1.0 1.1 Slaven, E.J. and Mathers, J., Differential diagnosis of shoulder and cervical pain: a case report. J Man Manip Ther. 2010 December; 18(4): 191–196. Level of evidence: Level 4
  2. Davidson RI., Dunn EJ., Metzmaker JN. The shoulder abduction test in the diagnosis of radicular pain in cervical extradural compressive monoradiculopathies. Spine. 6:441-6, 1981. Level of evidence: Level 4
  3. Rome, M., “Bakody’s test”, Physical therapy nation, 2013, (internet: www.physicaltherapynation.com/index.php?option=com_zoo&task=item&item_id=365&category_id=11&Itemid=12). Level of evidence: level 5
  4. Physiotutors. Shoulder Abduction Sign | Cervical Nerve Root Pathology. Available from: https://www.youtube.com/watch?v=8_AHkiiPYS8
  5. MALANGA, G., e.a., Musculoskeletal physical examination: an Evidence based approach, Mosby Elsevier, Philadelphia, 4 November 2005, p43 Level of evidence: Level 5
  6. Farmer et al. Cervical spine nerve root compression. An analysis of neuroforaminal pressures with varying head and arm positions. 1994 Aug 15;19(16):1850-5. Level of evidence: Level 5
  7. 7.0 7.1 Cox JM: Neck, Shoulder and Arm Pain: Mechanism, Diagnosis, Treatment. 3rd edition; 2005 Level of evidence: Level 5
  8. 8.0 8.1 Stenvers J.D., Overbeek, W.J., 5 Mobiliteitstesten van de schouder. Groningen, 20 januari 1977, (internet: http://www.nsastenvers.nl/5%20Mobiliteitstesten%20van%20de%20schouder.pdf). Level of evidence : level 5
  9. Physiotutors. Stenvers Tests | Shoulder Girdle Assessment. Available from: https://www.youtube.com/watch?v=vPLFbNi-R5g
  10. Physiotutors. Adson Test | Thoracic Outlet Syndrome. Available from: https://www.youtube.com/watch?v=7346RaEGKU
  11. MALANGA, G., e.a., Musculoskeletal physical examination: an Evidence based approach , Mosby Elsevier, Philadelphia, 4 November 2005, p51 Level of evidence: Level 5
  12. Physiotutors. Valsalva Maneuver | Cervical Radicular Syndrome. Available from: https://www.youtube.com/watch?v=k5o26XwpCt4
  13. Wainner, RS. et al. Diagnosis and nonoperative management of cervical radiculopathy. Journal of Orthopaedic & Sports Physical Therapy, 2000;30 ( 12) :728-744
Level of evidence : Level 2
  • Malanga G.A., et al. Provocative tests in cervical spine examination: historical basis and scientific analyses. Pain Physician. 2003;6:199-205. Level of evidence: Level 2
  • Zakharova-Luneva E, Jull G, Johnston V, O'Leary S. Altered trapezius muscle behavior in individuals with neck pain and clinical signs of scapular dysfunction. Journal of Manipulative and Phys. Ther. 2011 December; 35(5): 346-353. Level of Evidence: Level 4