Cervical Manual Muscle Testing: A Guide to Neck Muscle Assessment

Introduction

Cervical manual muscle testing is a fundamental component of the motor examination, allowing healthcare professionals to assess the strength, functional capabilities, and range of motion (ROM) of the neck muscles. By conducting manual muscle testing, clinicians can identify muscle imbalances, weaknesses, or dysfunctions that may contribute to pain, restricted range of motion, or impaired functional abilities in patients. This comprehensive guide will provide detailed information on the key neck muscles involved in manual muscle testing, outline the grading system used to assess muscle strength, describe the step-by-step evaluation procedures, and include essential equipment, indications, precautions, and contraindications for safe and effective testing.

Equipment Required To perform cervical manual muscle testing

The following equipment is necessary:

1. Goniometer: Used to measure the range of motion during flexion, extension, lateral flexion, and rotation evaluations.
2. Tape measure: Used to measure the range of motion during flexion evaluations.
3. Soft pillow: Provides support and comfort during patient positioning.
4. Plinth or table: Provides a stable surface for patient positioning during evaluation procedures.

Grading System: Assessing Muscle Strength

During manual muscle testing, the strength of neck muscles is graded using a standardized scale. The grading system categorizes muscle strength into different levels based on the patient’s ability to generate movement against resistance. The following are the commonly used grading systems for manual muscle testing:

• Grade 0: No muscle contraction or movement detected.
• Grade 1: Flicker or trace of muscle contraction, but no movement.
• Grade 2: Full range of motion with gravity eliminated (passive movement).
• Grade 3: Full range of motion against gravity but not against resistance.
• Grade 4: Full range of motion against strong resistance.
• Grade 5: Full range of motion against maximum resistance.

Range of Motion (ROM):

During cervical manual muscle testing, the range of motion for different movements is as follows:

1. Flexion: Typically ranging from 0 to 45 degrees.
2. Extension: Typically ranging from 0 to 45 degrees.
3. Lateral Flexion: Typically ranging from 0 to 45 degrees.
4. Rotation: Typically ranging from 0 to 90 degrees.

Evaluation Procedures: Step-by-Step Approach

To accurately assess the strength and range of motion of the neck muscles, healthcare professionals follow a systematic evaluation procedure.

FLEXION

ROM:

0 to 45 degrees with a goniometer
1.0 to 4.3 cm with a tape measure

A. PRIME MOVER :

Sternocliedomastoid(SCM)

• Origin:
  { Sternal head: Cranial aspect of the ventral surface of the manubrium.
  { Clavicular head: Superior border and anterior surface of the medial one-third of the clavicle.
• Insertion:
  The lateral surface of the mastoid process and the lateral half of the superior nuchal line of the occipital bone.
• Nerve supply/innervation:
  The spinal accessory nerve (C2 and C3 anterior rami).
• Other actions:
  Ipsilateral lateral flexion (to the same side) and contralateral rotation (to the opposite side) of the neck/head.
• Palpation Site:
  The anterolateral aspect of the neck

B. SECONDARY MOVERS :

• Rectus capitits anterior
• Rectus capitis lateralis
• Suprahyoid
• Infrahyoid
• Platysma
• Scalenes
• Longus capitis
• Longus colli

Cervical Manual Muscle Testing

GRADE 0-2

Position: Patient – The patient is lying on the side with the head supported by the pillow. Therapist – The therapist standing on the side of the patient.

• Palpation: On the side of the neck.
• Stabilization: Lower thorax
• Instructions to patient: Tell the patient to move his head forward.
• Substitutions: The corners of the subject’s mouth may be pulled down if the platysma contracts.
• Indication: Torticollis

GRADE 3-5

Position: Patient – Supine on a plinth. Therapist – Towards the head of the patient.

• Stabilization: The weight of the trunk from the thorax.
• Instructions: Tell the patient to lift up the head without lifting the shoulders
• Resistance: Apply the resistance on the forehead.

*The 2 SCM muscles may be tested individually by rotation of the head to one side with neck flexion.

EXTENSORS

ROM : 0° – 45°

A. PRIME MOVERS:

1. Splenius capitis

• Origin: Caudal half of the ligamentum nuchae and spinous processes of C7 and T1 to T4 vertebrae.
• Insertion: Occipital bone just inferior to the lateral one-third of the superior nuchal line into the mastoid process of the temporal bone.
• Nerve supply/ Innervation: Lateral branches of the dorsal primary cervical nerves.
• Other actions: Slight rotation and lateral flexion of the head.
• Palpation site: Under the lateral borders of the upper trapezius.

2. Semispinalis capitis

• Origin: Tips of the transverse processes of the C7 and T1 to T7 vertebrae.
• Insertion: Between the superior and inferior nuchal lines of the occipital bone.
• Nerve supply/Innervation: Dorsal primary divisions of the cervical nerves.
• Other actions: Unilaterally: Rotation of the spine to the opposite side.
• Palpation site: Under the lateral borders of the upper trapezius.

3. Cervicis muscles

• Origin: Spinous processes of the T3 to T6 vertebrae.
• Insertion: Posterior tubercles of C1 to C3.
• Innervation: Dorsal primary branch of the spinal nerves.
• Other actions: Unilaterally: Lateral flexion and rotation of the head.
• Palpation site: Under the lateral borders of the upper trapezius.

B. SECONDARY MOVER

Upper trapezius

Cervical Manual Muscle Testing

GRADE 0-2

Position: Patient – The patient is lying on the side with the head supported by the pillow. Therapist – The therapist standing on the side of the patient.

• Palpation: Under the lateral border of the trapezius.
• Stabilization: The weight of the trunk is stabilized on the table.
• Instructions to patient: Tell the patient to try to move the head towards the back.
• Substitutions: The patient tries to use back muscles.
• Indication: Weakness or spasm in extensors of the neck, in addition to this head action and sight, are blocked.

GRADE 3-5

Position: Patient – The patient is lying prone on the table. Therapist – Standing on the sides of the table.

• Stabilization: The weight of the trunk is stabilized from the scapula.
• Instructions to Patient: Tell the patient to pull the head up without lifting the shoulders.
• Substitutions: The patient tries to lift his trunk and use the back muscles.
• Resistance: Apply the resistance distally on the head.

*Neck lateral flexors and rotator muscles are generally tested in groups.

LATERAL FLEXION

ROM: 0° – 45°

MUSCLES:

Cervical Manual Muscle Testing

GRADE 0-2

Position: Patient – Supine Therapist – Standing on the side of the table.

• Stabilization: The shoulder is stabilized.
• Substitutions: The shoulder can be used by the patient to substitute the movement.
• Instructions to patient: Tell the patient to bend the head towards the sides.
• Palpation: The therapist palpates on the side of the neck which is tested.
• Indication: Torticollis or head drop on one side.

GRADE 3-5

Position: Patient- The patient is lying opposite to the side which is tested and the head is supported on the soft pillow. Therapist – Standing on the side of the table.

• Stabilization: The shoulder is stabilized.
• Substitutions: The shoulder can be used by the patient to substitute the movement.
• Instructions to patient: Tell the patient to bend the neck upward.
• Resistance: Apply the resistance on the head. Basically, the therapist put his hands above his ears.

ROTATION

ROM – 0° – 90° on both sides.
MUSCLES
SCM – contralateral rotator
Other rotators- Scalene
Semispinalis cervicis
Semispinalis capitus
Spinalis cervicis
Spinalis capitus
Erector spinae

Cervical Manual Muscle Testing

GRADE 0-2

Position: Patient – Sitting Therapist – Standing on the side of the chair.

• Stabilization: The opposite side shoulder is stabilized.
• Substitutions: The shoulder can be used by the patient to substitute the movement.
• Instructions to patient: Tell the patient to try to rotate the head to the side which is testing. But, in the case of SCM opposite side rotations are performed.
• Palpation: The therapist palpates on the side of the neck which is tested. But for SCM weakness palpation is done on the opposite side to which the head is rotated.
• Indication: Weak rotation of the neck.

GRADE 3-5

Position: Patient- The patient is lying opposite to the side which is tested and the head is supported on the soft pillow. Therapist – Standing on the side of the table.

• Stabilization: Stabilization of the shoulder of the same side.
• Substitutions: The shoulder can be used by the patient to substitute the movement.
• Instructions to patient: Tell the patient to rotate the head on the side which is testing. But, for SCM opposite side rotation is performed.
• Resistance: Apply the resistance on the head. Basically, the therapist put his hands above his ears.

* After performing the test carefully note the findings of the test in the patient’s assessment record.

Precautions and Contraindications

While performing cervical manual muscle testing, it is important to consider the following precautions and contraindications:

Precautions:

a. Ensure patient comfort and communicate clearly throughout the testing procedure.
b. Use caution when applying resistance to avoid excessive strain or injury to the patient.
c. Take note of any pain, discomfort, or adverse reactions reported by the patient during the evaluation.
d. Adhere to proper body mechanics to avoid strain or injury to the evaluator.

Contraindications:

a. Acute or severe neck pain or inflammation.
b. Recent neck or spinal surgery.
c. Unstable cervical spine.
d. Acute trauma or injury to the neck region.
e. Known or suspected cervical spine fractures or dislocations.
f. Any condition where manual muscle testing may exacerbate symptoms or pose a risk to the patient’s well-being.

Summary

Cervical manual muscle testing is a valuable assessment tool for evaluating neck muscle strength, range of motion, and functional capabilities. By following a systematic approach and using a standardized grading system, healthcare professionals can identify muscle imbalances, weaknesses, and dysfunctions in patients with neck pain or musculoskeletal disorders. It is important to consider the equipment required, indications, precautions, and contraindications to ensure safe and effective testing. Cervical manual muscle testing provides valuable insights for developing appropriate treatment plans, monitoring progress, and optimizing patient outcomes.

Glossary

• Range of Motion (ROM): The extent of movement that can be achieved in a specific joint or body part.
• Grading System: A standardized scale used to assess muscle strength during manual muscle testing.
• Flexion: The movement of bending or bringing a body part forward or towards the body’s midline.
• Extension: The movement of straightening or bringing a body part backward or away from the body’s midline.
• Lateral Flexion: The movement of bending or tilting a body part sideways or away from the body’s midline.
• Rotation: The movement of turning or twisting a body part around its axis.
• Stabilization: The act of providing support or maintaining a fixed position to ensure proper alignment and prevent unwanted movement during muscle testing.

Researches

• Diagnostic accuracy: Research studies have explored the diagnostic accuracy and reliability of cervical manual muscle testing in identifying specific muscle weakness or dysfunction in patients with various neck conditions. These studies may examine the sensitivity, specificity, and predictive values of different muscle testing procedures.
• Muscle imbalances: Some research investigates the muscle imbalances and asymmetries that can occur in the cervical region and their relationship to various musculoskeletal conditions such as neck pain, whiplash-associated disorders, or cervical radiculopathy. These studies may involve the use of manual muscle testing to assess and quantify muscle strength imbalances.
• Treatment outcomes: Studies may also investigate the effectiveness of specific therapeutic interventions, such as exercise programs or manual therapy techniques, in addressing muscle weakness or imbalances detected through manual muscle testing. These studies may examine the impact of treatment on muscle strength, functional outcomes, and symptom reduction.
• Reliability and validity: Research studies may assess the reliability and validity of cervical manual muscle testing procedures to ensure consistency and accuracy in the assessment. This includes examining inter-rater and intra-rater reliability, as well as comparing manual muscle testing findings with other objective measures or imaging techniques.
• Muscle testing in specific neck conditions: Studies may investigate the utility of cervical manual muscle testing in specific neck conditions such as whiplash-associated disorders, cervical radiculopathy, or cervical spine instability. The research may explore the association between muscle weakness or imbalances detected through manual muscle testing and the presence or severity of these conditions.
• Muscle strength changes following interventions: Research may examine changes in muscle strength and function assessed through manual muscle testing after various interventions such as physical therapy, exercise programs, manual therapy techniques, or surgical procedures. These studies aim to assess the effectiveness of interventions in improving muscle strength and functional outcomes.
• Comparison of manual muscle testing with other assessment tools: Studies may compare the findings of manual muscle testing with other objective assessment tools such as electromyography (EMG), isokinetic dynamometry, or functional movement tests. These comparisons help determine the concurrent validity and potential advantages of manual muscle testing in clinical practice.
• Muscle testing in different populations: Research studies may focus on specific populations such as athletes, older adults, or individuals with neurological conditions and examine the applicability and reliability of manual muscle testing techniques in these groups. These studies can provide insights into the use of manual muscle testing in different patient populations.

Please note that the specific research studies within these areas will require a search in academic databases using relevant keywords and filters. Accessing peer-reviewed journals and research databases will help you find the most up-to-date and relevant studies on cervical manual muscle testing.

FAQs

[faq question=”Q: What muscles are tested in the cervical spine?”] Key muscles tested include sternocleidomastoid, scalene, levator scapulae, trapezius, cervical extensors, and flexors.[/faq]

[faq question=”Q: Why test the neck manually?”] To evaluate strength impairments from cervical disorders, nerve injuries, postural dysfunction, or other neuromusculoskeletal conditions.[/faq]

[faq question=”Q: What is the cervical flexor test?”] Testing the patient’s ability to flex the neck against resistance applied to the forehead.[/faq]

[faq question=”Q: How is neck extension tested?”] The patient extends the neck while the examiner applies a downward force on top of the head.[/faq]

[faq question=”Q: How are cervical side bending tests performed?] Resistance is given laterally to the head while neck muscles contract to bend the neck to each side.[/faq]

[faq question=”Q: What is tested in cervical rotation?”] Strength of muscles that turn the head left and right against applied resistance.[/faq]

[faq question=”Q: How is neck muscle endurance assessed?] Sustained isometric holds in flexion, extension, or rotation.[/faq]

[faq question=”Q: What grading scales are used for the cervical spine?”] The usual 0-5 manual muscle test scale, or variations specific to the neck.[/faq]

[faq question=”Q: What cervical testing positions are used?”] Seated or supine are most common. Standing can also be used.[/faq]

[faq question=”Q: When is cervical testing indicated?] For suspected myopathy, cervical radiculopathy, injury, post-surgical or post-radiation assessments.[/faq]

[faq question=”Q: What precautions are needed with neck MMT?] Avoid overstretching. Have the patient report any increased neck pain or neurological symptoms.[/faq]

[faq question=”Q: Can neck strength be tested without equipment?”] Yes, no special equipment is required beyond the examiner’s hands for resistance.[/faq]

[faq question=”Q: Who performs cervical manual muscle testing?”] Physical therapists, athletic trainers, occupational therapists, rehabilitation specialists.[/faq]

[faq question=”Q: How often should cervical tests be repeated?] Periodic retesting helps gauge progress during neck rehabilitation.[/faq]

[faq question=”Q: How can I prepare for cervical MMT?] Relax neck muscles beforehand. Wear loose clothing that allows neck movement.[/faq]

[faq question=”Q: What conditions are assessed with cervical testing?”] Whiplash, arthritis, disc herniation, pinched nerves, torticollis and post-surgical.[/faq]

[faq question=”Q: Is approval needed for cervical manual testing?] No special approval is needed beyond the referring provider’s request.[/faq]

[faq question=”Q: Does insurance cover cervical manual testing?] Yes, cervical MMT is covered by most major medical insurance plans.[/faq]

[faq question=”Q: Where do I get training in cervical MMT?] Look for courses or continuing education through PT, OT and athletic training organizations.[/faq]

Muskan

Muskan Thakur is a skilled physical therapist based in Los Angeles, USA. She completed her Bachelor of Physical Therapy (BPT) from Delhi University in 2010. Ms. Thakur furthered her studies by completing a clinical residency program focused on orthopedic physical therapy at Duke University in the United States in 2012. She then attained her Master’s in Public Health (MPH) from the Institute of Public Health in Delhi in 2015. With over 10 years of experience, Ms. Thakur employs a holistic approach combining manual therapy, therapeutic exercise, education, and lifestyle modifications to treat neurological, orthopedic, and musculoskeletal conditions.