Patient Details: IRAS: 305349 Version No: 4 / 07.12.2021 Questionnaire Name: "Cervical Myelopathy Examination"

07/12/2021 Qualtrics Survey Software
IRAS: 305349
Version No: 4 / 07.12.2021
Questionnaire name: “Cervical Myelopathy Examination”
Patient details
Name
MRN
Age
Sex
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Ethnicity
Co-morbidities
Please tick the appropriate co-morbidities

Previous MI
Angina
Congestive HF
Cardiac Arrhythmia
Hypertension
Peripheral arterial disease
Respiratory disease
Hepatic disease
GI disease
Diabetes
Psychiatric Disease
Rheumatic disease
Previous stroke
Neuromuscular disease
Subarachnoid haemorrhage
Arthritis of Hand
Osteoarthritis of any joint
Psychiatric
Race adjusted BMI:

Normal
Overweight
Obese
Morbidly Obese
Block 2
Please tick the appropriate symptoms

Clumsy hands
Radicular pain
Neck pain
Shoulder pain
Upper arm pain (brachialgia)
Lower limb pain
Occipital skull pain
Numbness of hands
Numbness of feet
Paraesthesia in arms
Paraesthesia in hands
Paraesthesia in legs
Paraesthesia in feet
Gait difficulty
Altered subjective sensation in arms
Reduced subjective strength in arms
Altered subjective sensation in hands
Reduced subjective perceived strength in hands
Altered subjective sensation in legs
Reduced subjective strength in legs
Altered subjective sensation in feet
Sudden onset
Gradual onset
Stepwise onset
Constipation
Urinary hesitancy
Feeling of urinary retention
Breathing (inspiration) difficulty
Seizures
Heartburn (GORD)
No or weak erections
Dysfunctional sweating (heat induced sweating diminished, but spinal sweating
profuse)
Forced painful erections (priapism)
Urinary incontinence
Faecal incontinence
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Block 3
Please tick the appropriate neurological examination findings

Atrophy of neck muscles
Atrophy of shoulder muscles
Atrophy of arm muscles
Atrophy of hand muscles
Atrophy in leg muscles
Atrophy in feet
Lhermitte paraesthesia
Weakness (Pyramidal distribution)
Hyperreflexia
Hoffman's Reflex
Babinski Reflex
Absent abdominal reflex
Spurling test
Hyperreflexia in extended positions
Grip and release test
Inverted supinator reflex
Romberg test
Hyperactive pectoralis reflex
Spurling test
Duration of symptoms
Reduced light touch sensation in arms
Reduced light touch sensation in hands
Reduced light touch sensation in shoulders
Reduced light touch sensation in legs
Reduced light touch sensation in feet
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Reduced pinprick sensation in arms

Reduced pinprick sensation in hands
Reduced pinprick sensation in shoulders
Reduced pinprick sensation in legs
Reduced pinprick sensation in feet
Reduced temperature sensation in arms
Reduced temperature sensation in hands
Reduced temperature sensation in shoulders Reduced
temperature prick sensation in legs
Reduced temperature prick sensation in feet
Reduced joint position sensation in arms
Reduced joint position sensation in hands
Reduced joint position sensation in shoulders
Reduced joint position sensation in legs
Reduced joint position sensation in feet
Reduced vibration sensation in arms
Reduced vibration position sensation in hands
Reduced vibration position sensation in shoulders
Reduced vibration sensation in legs
Reduced vibration sensation in feet
Glove and stocking sensory loss in upper limbs
Glove and stocking sensory loss in lower limbs
Finger-to-nose test abnormal
Hand flip test abnormal
Heel-to-shin test abnormal
Tremor
Shoulder tenderness
Neck tenderness
Tenderness of cervical spine
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Reduced elbow flexion (semi-pronated) (C6)
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Reduced elbow extension (C7)

Reduced finger extension (C7)
Reduced finger flexion
Winging of scapula
Reduction of supraspinatus (arms up on side against resistance)
Reduction of infraspinatus (behind back)
Reduction of elbow flexion (brachioradialis)
Increased biceps reflex
Decreased biceps reflex
Increased supinator reflex
Decreased supinator reflex
Increased triceps reflex
Decreased triceps reflex
Wrist clonus
Reflex spread
Inverted reflex (combination of loss of reflex + reflex spread to muscle at lower level)
Reduced hip flexion
Reduced hip extension
Reduced knee extension
Reduced knee flexion
Reduced foot dorsiflexion
Reduced plantarflexion of the foot
Reduced big toe extension
Reduced toe extension
Reduced hip abduction
Reduced hip adduction
Reduced foot inversion
Reduced foot inversion
Reduced trunk flexion
Reduced trunk extension
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Increased knee reflex

Decreased knee reflex
Increased ankle reflex
Decreased ankle reflex
Ankle clonus
Increased tone in upper limbs
Increased tone in lower limbs
Increased tone in trunk
Mirror movement sign in upper limbs
Mirror movement sign in lower limbs
Unstable (eyes-open) gait
Unstable (eyes-closed) gait (sensory ataxia)
Block 4
Please tick appropriate CVS examination findings

Hypotension
Bradycardia
Reflex hypertension
Reflex tachycardia
Orthostatic hypotension
Retinal haemorrhages
SDNN (heart rate variability)
Dilated pupils
HR not up during Valsalva manoeuvre
HR not down after Valsalva manoeuvre
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Patients BP
Block 5
Please tick appropriate medications

Metformin
Other DM medication
Insulin
Anti-HTN medication
Statin
Long standing NSAID
Long standing steroids
DMOADs
Aspirin
Clopidogrel
DOAC
Warfarin
Others:
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MJOA
I. Motor dysfunction score of the upper extremities

Inability to move hands
Inability to eat with a spoon but able to move hand
Inability to button shirt but able to eat with a spoon
Able to button shirt with great difficulty
Able to button shirt with slight difficulty
II. Motor dysfunction score of the lower extremities

Complete loss of motor and sensory function
Sensory preservation without ability to move legs
Able to move legs but unable to walk
Able to walk on flat floor with a walking aid (i.e., cane or crutch)
Able to walk up and/or down stairs with hand rail
Moderate to significant lack of stability but able to walk up and/or down stairs without
hand rail
Mild lack of stability but walk unaided with smooth reciprocation No
dysfunction
III. Sensation
Complete loss of hand sensation
Severe sensory loss or pain
Mild sensory loss
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No sensory loss
IV. Sphincter dysfunction

Inability to urinate voluntarily
Marked difficulty with micturition
Mild to moderate difficulty with micturition Normal
micturition
Overall score
Mild
Moderate
Severe
JOACMEQ
While in the sitting position, can you look up at the ceiling by tilting
your head upward?
Impossible
Possible to some degree (with some efforts)
Possible without difficulty
Can you drink a glass of water without stopping despite the neck
symptoms?
24
Impossible
Possible to some degree (with some efforts) Possible without
difficulty
While in the sitting position, can you turn your head toward the
person who is seated to the side but behind you and speak to that
person while looking at his/her face?
Impossible
difficulty
Can you look at your feet when you go down the stairs?
Impossible
difficulty
Can you fasten the front buttons of your blouse or shirt with both
hands?
Impossible
Possible if I spend time.
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Can you eat a meal with your dominant hand using a spoon or a
fork?
Impossible
Possible if I spend time.
Can you raise your arm? (Answer for the weaker side.)
Impossible
Possible up to shoulder level
Possible though the elbow and/or wrist is a little flexed I can
raise it straight upward
Can you walk on a flat surface?

Impossible
Possible but slowly even with support
Possible only with the support of a handrail, a cane, or a walker
Possible but slowly without any support
Can you stand on either leg without the support of your hand? (the
need to support yourself)
Impossible with either leg
Possible on either leg for more than ten seconds
Possible on both legs individually for more than ten seconds
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Do you have difficulty in going up the stairs?

I have great difficulty
I have some difficulty
I have no difficulty
Do you have difficulty in one of the following motions; bending

forward, kneeling or stooping?
I have some difficulty I
have no difficulty
Do you have difficulty in walking more than 15 minutes?

I have some difficulty
I have no difficulty
Do you have urinary incontinence?

Always
Frequently
When retaining urine over a period of more than 2 hours
When sneezing or straining No
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How often do you go to the bathroom at night?

Three times or more
Once or twice
Rarely
Do you have a feeling of residual urine in your bladder after

voiding?
Most of the time
Sometimes
Rarely
Can you initiate (start) your urine stream immediately when you
want to void?
Usually not
Sometimes
Most of the time
How is your present health condition?

Poor
Fair
Good
Very good Excellent
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Have you been unable to do your work or ordinary activities as

well as you would like?
I have not been able to do them at all
I have been unable to do them most of the time
I have sometimes been unable to do them
I have been able to do them most of the time
I have always been able to do them
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Has your work routine been hindered because of the pain?

Greatly
Moderately
Slightly (somewhat)
Little (minimally) Not
at all
Have you been discouraged and depressed?

Always
Frequently
Sometimes
Rarely
Never
Do you feel exhausted?

Always
Frequently
Sometimes
Rarely
Never
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Have you felt happy?

Always
Frequently
Sometimes
Rarely
Never
Do you think you are in decent health?

Not at all (my health is very poor)
Barely (my health is poor)
Not very much (my health is average health)
Fairly (my health is better than average) Yes (I am
healthy)
Do you feel your health will get worse?

Very much so
A little bit at a time
Sometimes yes and sometimes no
Not very much
Not very much
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Regarding 0 as “no pain (numbness) at all” and 10 as “the most

intense pain (numbness) imaginable,” mark a point between 0 and
10 on the lines below to show the degree of your pain (numbness)
when your symptom was at its worst during the last week.
0 1 2 3 4 5 6 7 8 9 10
If you feel pain or stiffness in
your neck or
shoulders, mark the degree
If you feel tightness in your

chest, mark the degree
If you feel pain or numbness in your arms or hands, mark the
degree (If there is

pain in both limbs, then the worse of the two)
If you feel pain or numbness
from chest to toe,

mark the degree
Neck Disability Index
Pain Intensity
I have no pain at the moment
The pain is very mild at the moment
The pain is moderate at the moment
The pain is fairly severe at the moment
The pain is very severe at the moment
The pain is the worst imaginable at the moment
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Personal Care (Washing, Dressing, etc.)

I can look after myself normally without causing extra pain
I can look after myself normally, but it causes extra pain
It is painful to look after myself and I am slow and careful
I need some help but can manage most of my personal care
I need help every day in most aspects of self-care
I do not get dressed, I wash with difficulty and stay in bed
Lifting
I can lift heavy weights without extra pain
I can lift heavy weights, but it gives extra pain
Pain prevents me lifting heavy weights off the floor, but I can manage if they are
conveniently placed, for example on a table
Pain prevents me from lifting heavy weights, but I can manage light to medium weights if
they are conveniently positioned
I can only lift very light weights
I cannot lift or carry anything
Reading
I can read as much as I want to with no pain in my neck
I can read as much as I want to with slight pain in my neck
I can read as much as I want with moderate pain in my neck
I can’t read as much as I want because of moderate pain in my neck
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I can hardly read at all because of severe pain in my neck I cannot

read at all
Headaches
I have no headaches at all
I have slight headaches, which come infrequently
I have moderate headaches, which come infrequently
I have moderate headaches, which come frequently
I have severe headaches, which come frequently
I have headaches almost all the time
Concentration
I can concentrate fully when I want to with no difficulty
I can concentrate fully when I want to with slight difficulty
I have a fair degree of difficulty in concentrating when I want to
I have a lot of difficulty in concentrating when I want to
I have a great deal of difficulty in concentrating when I want to
I cannot concentrate at all
Work
I can do as much work as I want to
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I can only do my usual work, but no more

I can do most of my usual work, but no more
I cannot do my usual work
I can hardly do any work at all
I can’t do any work at all
Driving
I can drive my car without any neck pain
I can drive my car as long as I want with slight pain in my neck
I can drive my car as long as I want with moderate pain in my neck
I can’t drive my car as long as I want because of moderate pain in my neck
I can hardly drive at all because of severe pain in my neck
I can’t drive my car at all
Sleeping
I have no trouble sleeping
My sleep is slightly disturbed (less than 1 hr sleepless)
My sleep is mildly disturbed (1-2 hrs sleepless)
My sleep is moderately disturbed (2-3 hrs sleepless)
My sleep is greatly disturbed (3-5 hrs sleepless)
My sleep is completely disturbed (5-7 hrs sleepless)
Recreation
I am able to engage in all my recreation activities with no neck pain at all I am able to
engage in all my recreation activities, with some pain in my neck
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I am able to engage in most, but not all of my usual recreation activities because of pain
in my neck
I am able to engage in a few of my usual recreation activities because of pain in my neck

I can hardly do any recreation activities because of pain in my neck
I can’t do any recreation activities at all
24

Patient Details: IRAS: 305349 Version No: 4 / 07.12.2021 Questionnaire Name: "Cervical Myelopathy Examination"

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Patient Details: IRAS: 305349 Version No: 4 / 07.12.2021 Questionnaire Name: "Cervical Myelopathy Examination"

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07/12/2021 Qualtrics Survey Software

Please tick the appropriate co-morbidities

Race adjusted BMI:

Please tick the appropriate symptoms

Please tick the appropriate neurological examination findings

Reduced pinprick sensation in arms

Reduced elbow flexion (semi-pronated) (C6)

Reduced elbow extension (C7)

Increased knee reflex

Please tick appropriate CVS examination findings

Please tick appropriate medications

Long standing NSAID

Long standing steroids

I. Motor dysfunction score of the upper extremities

II. Motor dysfunction score of the lower extremities

IV. Sphincter dysfunction

Can you walk on a flat surface?

Do you have difficulty in going up the stairs?

Do you have difficulty in one of the following motions; bending

Do you have difficulty in walking more than 15 minutes?

Do you have urinary incontinence?

How often do you go to the bathroom at night?

Do you have a feeling of residual urine in your bladder after

How is your present health condition?

Have you been unable to do your work or ordinary activities as

Has your work routine been hindered because of the pain?

Have you been discouraged and depressed?

Do you feel exhausted?

Have you felt happy?

Do you think you are in decent health?

Do you feel your health will get worse?

Regarding 0 as “no pain (numbness) at all” and 10 as “the most

If you feel pain or stiffness in

If you feel tightness in your

If you feel pain or numbness in your arms or hands, mark the

degree (If there is

If you feel pain or numbness

from chest to toe,

Neck Disability Index

Personal Care (Washing, Dressing, etc.)

I can hardly read at all because of severe pain in my neck I cannot

I can only do my usual work, but no more

I am able to engage in a few of my usual recreation activities because of pain in my neck

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