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1. Cervical flexibility
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1.1 Range of motion, upper cervical
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Three sub-factors
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a) Flexion-extension
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a) < 68°
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a) 20% below reference values of normative control data[44] resulting in 97% specificity.
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b) Passive rotation in maximal flexed position
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b) < 32°
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b) 18-29% below reference values of normative control data[45–47]. Also discriminating cut off for cervicogenic headache[47, 48].
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Qualifier: Either a) or b)
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1.2. Range of motion, lower cervical
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Flexion-extension
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< 17°
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35% below reference values of normative control data[44] resulting in 94% specificity.
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1.3. Range of motion, upper and lower cervical
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Axial rotation
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< 109°
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20% below reference values of normative control data[44] resulting in 97 % specificity.
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2. Cervical strength
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2.1.Cranio-cervical flexion test
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Three sub-factors
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a) Maximal voluntary contraction (MVC)
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a) < 2,5 Nm
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a) Empirical experience, value indicating clear impairment (Shaun O’Leary, personal communication)
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b) Endurance (50 % MVC)
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b) < 20 sec
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b) 88,5% specificity based on normative control data (Pilot study, unpublished data, n = 26).
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Qualifier: Either a) or b)
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2.2. Cervico-thoracic test
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a) Flexion MVC
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a) < 40 N
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a) 95% specificity according to data simulation based on[49, 50].
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b) Extension MVC
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b) < 140 N
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b) 95 % specificity according to data simulation based on[49, 50].
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Qualifier: Either a) or b)
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2.3. Arm strength in lifting task
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a) Cervical Progressive Isoinertial lifting evaluation test (C-PILE)[51]
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a) Max weight / adjusted body weight[52]: <0,12 kg/kg[28, 53]
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a) Cut off to discriminate between neck pain and healthy: Specificity 81%[53]
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b) Subjective rating of the ability to carry and to lift
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b) At least answer “rather bad, rather difficult” on the questions “Because of your neck problems, how do you manage to carry/lift?” (≥4 on the scale 1 = Very good, no problem; 6 = Very bad, very difficult/impossibly)
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b) Specificity data N/A. Chosen cut-off renders 47% of women with neck pain positive. (non-published data, ISRCTN92199001)
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Qualifier: a) and b)
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Comment: From a clinical perspective, we thought it important to combine estimates of physical capability and subjective rating in the treatment decision process.
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3. Trapezius myalgia
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a) Diagnosed trapezius myalgia right or left
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a) Criteria according to Ohlsson and coworkers[27], with amendments[26].
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a) Specificity N/A. In an attempt to sharpen and objectify the trapezius myalgia criteria we have added pain pressure measurements.
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b) Pain pressure threshold of the upper trapezius muscles
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b) < 175 N right trapezius, < 168 N left trapezius
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b) 20 % below reference values of nonspecific neck pain subjects without trapezius myalgia.
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Qualifier: a) and b)
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The combination of criteria predicts 40% positive tests (non-published data, ISRCTN92199001).
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4. Cervicogenic headache
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Diagnosed cervicogenic headache
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Criteria of the Cervicogenic Headache International Study Group[54] with amendment of reduced range of motion specific for the upper cervical levels and palpable upper cervical joint dysfunction[55].
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The reason for the amendment is to increase the sensitivity and specificity[55]. Note that the tests of reduced upper cervical range of motion are the same as for cervical flexibility 1a and b.[44, 47, 48]
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5. Sensorimotor control
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5.1. Symptoms and activity limitations
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a) Rather strong/often dizziness or balance disturbances: (≥4 on both questions. Scale 1–6.)[28]
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a) Prediction 11%.
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Two sub-factors
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Combinations of: - Dizziness or balance disturbances
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b) Light dizziness or balance disturbances (3 on both questions, or >3 on one. Scale 1–6.)[28] and headache associated to neck problems (but not cervicogenic headache)
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b) or c) Prediction 30%.
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- Headache associated to neck problems - Difficulties to rotate the head due to neck problems
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c) Light dizziness or balance disturbances and, due to neck problems, difficulties to rotate the head
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Disturbances of sensorimotor control and its associations to symptoms like dizziness/balance disturbances and headache is supported in the literature (for references see[56, 57].
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(≥4 on scale 1–6.)
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To predict the number of positive cases for the combinations in a), b) and c) we used 117 women with nonspecific neck pain (Own non-published data, ISRCTN92199001):
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Qualifier: Either a) or b)or c)
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5.2. Cervical motor function
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< 170°/sec
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50% below reference control data giving 97% specificity[32]
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Peak speed of cervical axial rotation.
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Reduced ability to perform fast cervical rotations may reflect altered sensorimotor function in neck pain patients[32].
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