Range Of Motion And Maneuvers

The neck is the most mobile portion of the spine, remarkable for its seven fragile vertebrae supporting the 10- to 15-pound ball of the head. Flexion and extension occur primarily between the skull and C1 (the atlas), rotation at C1-C2 (the axis), and lateral bending at C2-C7.

Limitations in range of motion may reflect stiffness from arthritis, pain from trauma, or muscle spasm such as torticollis.

Ask the patient to perform the following maneuvers, and check for smooth, coordinated motion:

■ Flexion. Touch the chin to the chest.

■ Extension. Look up at the ceiling.

■ Rotation. Turn the head to each side, looking directly over the shoulder.

It is important to assess any complaints or findings of neck, shoulder, or arm pain or numbness for possible cervical cord or nerve root compression. See Table 15-2, Pains in the Neck (p. 523).

■ Lateral bending. Tilt the head, touching each ear to the corresponding shoulder.

Tenderness, loss of sensation, or impaired movement warrants careful neurologic testing of the neck and upper extremities.

Now assess range of motion in the spinal column.

Tenderness at C1-C2 in rheumatoid arthritis suggests possible risk of subluxation and high cervical cord compression.

■ Flexion. Ask the patient to bend forward to touch the toes (flexion). Note the smoothness and symmetry of movement, the range of motion, and the curve in the lumbar area. As flexion proceeds, the lumbar concavity should flatten out.

Scoliosis Physical Examination

Deformity of the thorax on forward bending in scoliosis.

Persistence of lumbar lordosis suggests muscle spasm or ankylosing spondylitis.

Lordosis Bend

You may wish to measure the degree of flexion of the spine with the patient standing and bending forward. Mark the spine at the lumbosacral junction, then 10 cm above and 5 cm below this point. A 4-cm increase between the two upper marks is normally seen The distance between the lower two marks should be unchanged.

Ankylosing Spondylitis

■ Extension. Place your hand on the posterior superior iliac spine, with your fingers pointing toward the midline, and ask the patient to bend backward as far as possible.

Decreased spinal mobility in osteoarthritis and ankylosing spondylitis, among other conditions

■ Rotation. Stabilize the pelvis by placing one hand on the patient's hip and the other on the opposite shoulder. Then rotate the trunk by pulling the shoulder and then the hip posteriorly. Repeat these maneuvers for the opposite side.

■ Lateral bending. Again stabilize the pelvis by placing your hand on the patient's hip. Ask the patient to lean to both sides as far as possible.

Laminated Physical Exam ManeuversHip Pain Physical Exam ManuversShoulder Exam Maneuvers

As with the neck, pain or tenderness with these maneuvers, particularly with radiation into the leg, warrants careful neurologic testing of the lower extremities.

H The Hip_

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