Cervical Spine Assessment
Select All
Clear All
Clear CBG free text
Expand All
Collapse All
+
Subjective
Patient unique id
Please convert the below information into Physiotherapy soap note and also add Opportunities for Improvement
Type of assessment
Initial Evaluation
Follow Up Note
+
Side (global selection)
Left
Right
Bilateral
+
Objective Assessment
+
On examination
+
ROM
Flexion
Full range of motio - 50–60°
Reduced range of motion
Reduced range of motion due to pain
Full range of motion with pain
Extension
Full range of motion - 60–70°
Reduced range of motion
Reduce range of motion due to pain
Full range of motion with pain
Rotation Right
Full range of motion - 70–90°
Reduced range of motion
Reduced range of motion due to pain
Full range of motion with pain
Rotation Left
Full range of motion - 70–90°
Reduced range of motion
Reduced range of motion due to pain
Full range of motion with pain
Right Lateral Flexion
Full range of motion - 35–45°
Reduced range of motion
Reduced range of motion due to pain
Full range of motion with pain
Left lateral Flexion
Full range of motion - 35–45°
Reduced range of motion
Reduced range of motion due to pain
Full range of motion with pain
+
Muscle Power
Flexion
0 – No visible or palpable contraction
1 – Slight contraction, no movement
2 – Full movement with gravity eliminated
5 – Full movement against gravity with strong resistance (normal strength)
5 – Full movement against gravity with strong resistance (normal strength) with pain
Extension
0 – No visible or palpable contraction
1 – Slight contraction, no movement
2 – Full movement with gravity eliminated
3 – Full movement against gravity, no added resistance
4 – Full movement against gravity with moderate resistance
5 – Full movement against gravity with strong resistance (normal strength)
5 – Full movement against gravity with strong resistance (normal strength) with pain
Right lateral flexion
0 – No visible or palpable contraction
1 – Slight contraction, no movement
2 – Full movement with gravity eliminated
3 – Full movement against gravity, no added resistance
4 – Full movement against gravity with moderate resistance
5 – Full movement against gravity with strong resistance (normal strength)
5 – Full movement against gravity with strong resistance (normal strength) with pain
Left lateral flexion
0 – No visible or palpable contraction
1 – Slight contraction, no movement
2 – Full movement with gravity eliminated
3 – Full movement against gravity, no added resistance
4 – Full movement against gravity with moderate resistance
5 – Full movement against gravity with strong resistance (normal strength)
5 – Full movement against gravity with strong resistance (normal strength) with pain
Right rotation
0 – No visible or palpable contraction
1 – Slight contraction, no movement
2 – Full movement with gravity eliminated
3 – Full movement against gravity, no added resistance
4 – Full movement against gravity with moderate resistance
5 – Full movement against gravity with strong resistance (normal strength)
+
Posture
Cranio‑Cervical Alignment (Sagittal Plane)
Neutral cranio‑cervical posture
Anterior head translation (forward head posture)
Posterior head translation (retracted head posture)
Upper cervical extension (“chin poke”)
Upper cervical flexion (“chin tuck”)
Cervical Curve (Lordosis)
Physiologic cervical lordosis
Cervical hypolordosis (flattened/straightened curve)
Cervical hyperlordosis (excessive inward curve)
Shoulder Girdle / Upper Thorax
Scapular girdle level and symmetrical
Right shoulder elevation
Left shoulder elevation
Bilateral shoulder protraction (rounded shoulders)
Excessive thoracic kyphosis (hyperkyphosis)
Reduced thoracic kyphosis (hypokyphosis)
Scapula Position - Right
Neutral
Protracted
Retracted
Elevated
Depressed
Downwardly rotated
Upwardly rotated
Winging
Scapula Position - Left
Neutral
Protracted
Retracted
Elevated
Depressed
Downwardly rotated
Upwardly rotated
Winging
+
Dermatomes
C2 - Right
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
Occiput / upper posterior neck
C3 - Right
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
Lateral neck
C4 - Right
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
Supraclavicular / top of shoulder
C5 - Right
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
Deltoid
C6 - Right
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
Outer aspect of the forearm and thumb
C7 - Right
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
Middle finger
C8 - Right
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
Little finger and medial aspect of the forearm
T1 - Right
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
Medial epicondyle
C2 - Left
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
Occiput / upper posterior neck
C3 - Left
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
Lateral neck
C4 - Left
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
Supraclavicular / top of shoulder
C5 - Left
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
Deltoid
C6 - Left
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
Outer aspect of the forearm and thumb
C7 - Left
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
Middle finger
C8 - Left
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
Little finger and medial aspect of the forearm
T1 Left
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
Medial epicondyle
+
Myotomes
C1 - Right
Normal
Weak
Painful
No contraction
Fatigable
Neck flexion
C2 - Right
Normal
Weak
Painful
No contraction
Fatigable
Neck flexion (longus capitis, rectus capitis anterior)
C3 - Right
Normal
Weak
Painful
No contraction
Fatigable
Neck lateral flexion
C4 - Right
Normal
Weak
Painful
No contraction
Fatigable
Shoulder elevation (trapezius, levator scapulae)
C5 - Right
Normal
Weak
Painful
No contraction
Fatigable
Shoulder abduction / elbow flexion (deltoid, biceps)
C6 - Right
Normal
Weak
Painful
No contraction
Fatigable
Wrist extension (extensor carpi radialis group)
C7 - Right
Normal
Weak
Painful
No contraction
Fatigable
Elbow extension / wrist flexion
C8 - Right
Normal
Weak
Painful
No contraction
Fatigable
Thumb extension / finger flexion
T1 - Right
Normal
Weak
Painful
No contraction
Fatigable
Finger abduction/adduction
C1 - Left
Normal
Weak
Painful
No contraction
Fatigable
Neck flexion
C2 - Left
Normal
Weak
Painful
No contraction
Fatigable
Neck lateral flexion
C3 - Left
Normal
Weak
Painful
No contraction
Fatigable
Shoulder elevation
C4 - Left
Normal
Weak
Painful
No contraction
Fatigable
Shoulder elevation
C5 - Left
Normal
Weak
Painful
No contraction
Fatigable
Shoulder abduction / elbow flexion
C6 - Left
Normal
Weak
Painful
No contraction
Fatigable
Wrist extension
C7 - Left
Normal
Weak
Painful
No contraction
Fatigable
Elbow extension / wrist flexion
C8 - Left
Normal
Weak
Painful
No contraction
Fatigable
Thumb extension / finger flexion
T1 - Left
Normal
Weak
Painful
No contraction
Fatigable
Finger abduction/adduction
+
On Palpation Left
+
Tenderness
Superficial Anterior / Lateral Neck
Sternocleidomastoid
Anterior scalene
Middle scalene
Posterior scalene
Posterior Cervical Extensors and Stabilizers
Splenius capitis
Splenius cervicis
Semispinalis capitis
Semispinalis cervicis
Cervical multifidus
Levator scapulae
Upper trapezius
Scapular and Shoulder Girdle Muscles
Middle trapezius
Lower trapezius
Rhomboid major
Rhomboid minor
Serratus anterior
Pectoralis minor
Pectoralis major
Latissimus dorsi
Teres major
Teres minor
Supraspinatus
Infraspinatus
Subscapularis
Suboccipital Group
Rectus capitis posterior major
Rectus capitis posterior minor
Obliquus capitis superior
Obliquus capitis inferior
+
On Palpation Right
+
Tenderness
Superficial Anterior / Lateral Neck
Sternocleidomastoid
Anterior scalene
Middle scalene
Posterior scalene
Posterior Cervical Extensors and Stabilizers
Splenius capitis
Splenius cervicis
Semispinalis capitis
Semispinalis cervicis
Cervical multifidus
Levator scapulae
Upper trapezius
Scapular and Shoulder Girdle Muscles
Middle trapezius
Lower trapezius
Rhomboid major
Rhomboid minor
Serratus anterior
Pectoralis minor
Pectoralis major
Latissimus dorsi
Teres major
Teres minor
Supraspinatus
Infraspinatus
Subscapularis
Suboccipital Group
Rectus capitis posterior major
Rectus capitis posterior minor
Obliquus capitis superior
Obliquus capitis inferior
+
Special Test
+
Special Test
Spurling test
Negative
Postive
Distraction Test
Negative
Positive
Cervical Spondylosis Pain in the neck Heavines on the upper trapezius Pins and Needles Tender in the Midline of C5, C6, C7
Rhomberg Test
Negative
Positive
Lhermitte's sign
Negative
Positive
Grip and release test
Negative
Positive
Cervical Myelopathy Patients typically will be in 60s, 70s or 80s Course pain in the neck Tingling Neurological Symptoms Occipital Headache Unsteady on feet Unbalanced walking Difficulties in ADL’s Lack of coordination Pain Reduced ROM Rhomberg Test Lhermitte's sign- Electrical shock-like sensation Grip and release test (Have to do 20 times in a minute)
+
Assessment
Diagnosis
+
Plan
+
Treatment Given
+
Myofascial Trigger Point release
Superficial Anterior / Lateral Neck
Sternocleidomastoid
Anterior scalene
Middle scalene
Posterior scalene
Posterior Cervical Extensors and Stabilizers
Splenius capitis
Splenius cervicis
Semispinalis capitis
Semispinalis cervicis
Cervical multifidus
Levator scapulae
Upper trapezius
Scapular and Shoulder Girdle Muscles
Middle trapezius
Lower trapezius
Rhomboid major
Rhomboid minor
Serratus anterior
Pectoralis minor
Pectoralis major
Latissimus dorsi
Teres major
Teres minor
Supraspinatus
Infraspinatus
Subscapularis
Suboccipital Group
Rectus capitis posterior major
Rectus capitis posterior minor
Obliquus capitis superior
Obliquus capitis inferior
Taping
Advised on do's and don'ts
Isometric strengthening
Neck muscle
Upper back and shoulder girdle strenghtening
Upper limb stretching videos shared
Next visit
After 1 week
After 2 weeks
After 1 month
👁
Preview
Preview
Copy Preview
Copy for Word
Select All Preview
Copied! Now paste into Word.
Automatic copy is not supported. Click "Select All Preview", then press
Ctrl+C
(or
Cmd+C
) to copy, then paste into Word.