Testing the Muscles of the Neck

Capital Extension
Rectus capitis posterior minor Obliquus capitis
superior

Rectus capitis
posterior major
Splemus
capitis Obliquus capitis
Q2 inferior

Longissimus
Q5 capitis
Semispinalis
capitis

POSTER OR FIGURE 3-1

 Suboccipital nerve (n.)
C1 To: Rectus capitis posterior major
Rectus capitis posterior minor
Obliquus capitis superior
Obliquus capitis inferior

Greater occipital n
To: Semispmalis capitis
Longissimus capitis
Splemus capitis
Spinalis capitis

Other capital extensors

receive innervation from
C3 down as far as T1

FIGURE 3-2
Range of Motion

0° to 25°

Table 3-1

CAPITAL EXTENSION

I.D. Muscle Origin Insertion

56 Rectus capitis posterior Axis (spinous process)

major Occiput (inferior
nuchal line laterally)

57 Rectus capitis posterior Atlas (tubercle of posterior

Occiput (inferior
minor arch)
nuchal line
medially)

60 Longissimus capitis Temporal bone

T1-T5 vertebrae (transverse (mastoid process,
processes)C4-C7 vertebrae posterior surface)
(articular processes)

58 Obliquus capitis Atlas (transverse process)

superior Occiput (between
superior and inferior
nuchal lines)

59 Obliquus capitis inferior Axis (lamina and spinous

Atlas (transverse
process)
process, inferior-
posterior surface)

61 Splenius capitis Ligamentum nuchaeC7-T4

Temporal bone
vertebrae (spinous
(mastoid
processes)
process)Occiput
(below superior
nuchal line)

Semispinalis capitis C7-T6 vertebrae (transverse Occiput (between

62
(distinct medial part processes)C4- superior and
I.D. Muscle Origin Insertion

often named Spinalis C6 vertebrae (articular

inferior nuchal lines)
capitis) processes)

124 Trapezius (upper) Occiput (external Clavicle (posterior

protuberance and superior border of lateral 1/3)
nuchal line, middle 1/3)C7
(spinous
process)Ligamentum
nuchae

63 Spinalis capitis Medial part of Semispinalis Occiput (between

capitis, usually blended superior and inferior
inseparably nuchal lines)

Other

83
Sternocleidomastoid
(posterior)

Grade 5 (Normal) and Grade 4 (Good)

Position of Patient:

Prone with head off end of table. Arms at sides.

Position of Therapist:
Standing at side of patient next to the head. One hand provides resistance over the occiput
(Figure 3-3). The other hand is placed beneath the overhanging head, prepared to support the
head should it give way with resistance, which is applied directly opposite to the movement of
the head.
Patient extends head by tilting chin upward in a nodding motion. (Cervical spine is not
extended.)

Instructions to Patient:

“Look at the wall. Hold it. Don’t let me tilt your head down.”

Grading

Grade 5 (Normal):
Patient completes available range of motion without substituting cervical extension. Tolerates
maximum resistance. (This is a strong muscle group.)
Grade 4 (Good):

Patient completes available range of motion without substituting cervical extension. Tolerates
strong to moderate resistance.

Grade 3 (Fair)

Position of Patient:

Prone with head off end of table and supported by therapist. Arms at sides.

Position of Therapist:
Standing at side of patient’s head. One hand should remain under the head to catch it should the
muscles fail to hold position (Figure 3-4).
 FIGURE 3-4

Instructions to Patient:

“Look at the wall.”

Test:

Patient completes available range of motion with no resistance.

Grade 2 (Poor), Grade 1 (Trace), and Grade 0 (Zero)

Position of Patient:
Supine with head on table. Arms at sides. Note: The gravity minimized position (side-lying) is
not recommended for any of the tests of the neck for grades 2 (Poor) and below because test
artifacts are created by the therapist in attempting to support the head without providing
assistance to the motion.
Position of Therapist:

Standing at end of table facing patient. Head is supported with two hands under the occiput.
Fingers should be placed just at the base of the occiput lateral to the vertebral column to attempt
to palpate the capital extensors (Figure 3-5). Head may be slightly lifted off table to reduce
friction.
Test:

Patient attempts to look back toward therapist without lifting the head from the table.

Instructions to Patient:

“Tilt your chin up,” OR “Look back at me. Don’t lift your head.”

Grading Grade 2 (Poor):

Patient completes limited range of motion.

Grade 1 (Trace) and Grade 0 (Zero):

Palpation of the capital extensors at the base of the occiput just lateral to the spine may be
difficult; the splenius capitis lies most lateral and the recti lie just next to the spinous process.
Helpful Hints

• Clinicians are reminded that the head is a very heavy object suspended on thin support.
Whenever testing with the patient’s head off the table, extreme caution should be used for the
patient’s safety, especially in the presence of suspected or known neck or trunk weakness.
Always place a hand under the head to catch it should the muscles give way.
• Significant weakness of the capital extensor muscles combined with laryngeal and
pharyngeal weakness can result in a nonpatent airway. There also may be inability to swallow.
Both of these problems occur because the loss of capital extensors leaves the capital flexors
unopposed, and
the resultant head position favors the chin tucked on the chest, especially in the supine
position.1 This problem is not limited to patients with severe polio paralysis; it is also evident in
patients with severe rheumatoid arthritis. Patients with chronic forward head posture also
commonly have weak cervical extensors.
 FLEXION AND
EXTENSION OF
THE
HEAD AND NECK

::.AP rAL FLEXION CAPITAL EXTENSION

CERVICAL FLEXION CERVICAL EXTENSION

COMBINED FLEXION COMBINED EXTENSION

(CAPITAL AND CERVICAL) (CAPITAL AND CERVICAL)

PLATE 1

Cervical Extension
 Splemus
cervicis Semispinalis
cervicis
Longissimus
cervicis
lliocostalis
cervicis

Rib 3

POSTERIOR FIGURE 3-6

 FIGURE 3-7

Range of Motion

0° to less than 30°

Table 3-2

CERVICAL EXTENSION

I.D. Muscle Origin Insertion

64 Longissimus T1-T5 vertebrae (transverse C2-C6 vertebrae

(transverse
I.D. Muscle Origin Insertion

cervicis processes) variable processes)

65 Semispinalis T1-T5 vertebrae (transverse

Axis (C2)-C5
cervicis processes)
vertebrae
(spinous
processes)

66 Iliocostalis cervicis Ribs 3-6 (angles)

C4-C6 vertebrae
(transverse
processes,
posterior
tubercles)

67 T3-T6 vertebrae (spinous

Splenius cervicis C1-C3 vertebrae
processes)
(may be absent or (transverse
variable) processes)

124 Trapezius (upper) Clavicle

Occiput (protuberance and
(posterior border
superior nuchal line, middle
of lateral 1/3)
1/3)C7 (spinous
process)Ligamentum nuchae T1-
T12 vertebrae occasionally

68 Spinalis cervicis C7 and often C6 vertebrae

Axis (spinous
(often absent) (spinous processes)Ligamentum
process)C2-C3
nuchaeT1-T2 vertebrae
vertebrae
occasionally
(spinous
processes)

Others

69 Interspinales
cervicis

70 Intertransversarii
cervicis
I.D. Muscle Origin Insertion

71 Rotatores cervicis

94 Multifidi

127 Levator scapulae

The cervical extensor muscles are limited to those that act only on the cervical spine with motion
centered in the lower cervical spine.2,3

Grade 5 (Normal) and Grade 4 (Good)

Position of Patient:

Prone with head off end of table. Arms at sides.

Position of Therapist:
Standing next to patient’s head. One hand is placed over the parieto-occipital area for resistance
(Figure 3-8). The other hand is placed below the chin, ready to catch the head if it gives way
suddenly during resistance.

Test:

Patient extends neck without tilting chin.

Instructions to Patient:

“Push up on my hand but keep looking at the floor. Hold it. Don’t let me push it down.”

Grading

Grade 5 (Normal):
Patient completes full range of motion and holds against maximum resistance. Therapist must
use clinical caution because these muscles are not strong, and their maximum effort will not
tolerate much resistance.

Grade 4 (Good):

Patient completes full range of motion against moderate resistance.

Grade 3 (Fair)

Position of Patient:

Prone with head off end of table. Arms at sides.

Position of Therapist:
Standing next to patient’s head with one hand supporting (or ready to support) the forehead
(Figure 3-9).
Test:

Patient extends neck without looking up or tilting chin.

Instructions to Patient:

“Lift your forehead from my hand and keep looking at the floor.”

Grading Grade 3 (Fair):

Patient completes range of motion but takes no resistance.

Alternate Test for Grade 3:

This test should be used if there is known or suspected trunk extensor weakness. The therapist
should always have an assistant participate to provide protective guarding under the patient’s
forehead. This test is identical to the preceding Grade 3 test except that stabilization is provided
by the therapist if needed to accommodate trunk weakness. Stabilization is provided to the upper
back by the forearm placed over the upper back with the hand cupped over the shoulder (Figure
3-10).

Grade 2 (Poor), Grade 1 (Trace), and Grade 0 (Zero)

Position of Patient:

Supine with head fully supported by table. Arms at sides.

Position of Therapist:

Standing at head end of table facing the patient. Both hands are placed under the head. Fingers
are distal to the occiput at the level of the cervical vertebrae for palpation (Figure 3-11).

FIGURE 3-11

Test:

Patient attempts to extend neck into table.

Instructions to Patient:

“Try to push your head down into my hands.”

Grading Grade 2 (Poor):

Patient moves through small range of neck extension by pushing into therapist’s hands.

Grade 1 (Trace):

Contractile activity palpated in cervical extensors.

Grade 0 (Zero):

No palpable muscle activity.

Combined Neck Extension

(Capital plus Cervical)

Range of Motion
0° to 45°

Capital Extension Model is prone with head off the

end of the table. model's arms are at
his side. The examiner stands at the
side of the model next to the head.
The examiner applies resistance
with one hand over the occiput, and
the other hand is placed under the
head should it give way with applied
resistance.

Capital Flexion Model is supine with head on table

and arms at side. The examiner is
standing at head of table facing
patient. Both hands of examiner are
cupped under the mandible (chin)
and touching the cheeks to give
resistance in an upward and
backward direction.

Cervical Extension Model is prone with head off the

end of table and arms at side. The
examiner stands next to patients
head. The examiner places one hand
over the parieto-occipital for
resistance and the other hand is
placed under the chin ready to catch
the head if it gives way.
Cervical Flexion Model is supine with arms at their
side, and head on table. The
examiner stands next to patients
head. The examiner places one
hand on the model's forehead for
resistance, and the other hand may
be placed on model's chest.
Stabilization is only needed when
trunk is weak.

Capital plus Cervical Model is prone with head off the

Extension table and arms at side. The
1
examiner stands next to patients head and places one A
handover parieto-occipital area to apply downward and
forward resistance. The other hand is placed under the chin
to catch the head if it gives way.

Capital plus Cervical Model is supine with head on table

Flexion and arms at side. The examiner
stands at the side of the table at
the level of the model's shoulder.
One hand is placed on the
forehead for resistance and the
other hand may be used for
stabilization of the trunk if it is
weak.
Neck Flexion with Patient is supine with head
Rotation supported on table and turned to the
right to test the left
sternocleidomastoid. Therapist
faces the patient with one hand
placed on the temporal area above
the ear for resistance. Patient raises
head from table against resistance,
keeping head turned throughout the
movement.