The cervical (Cx) spine is a complex area and is often seen as intimidating by therapists of all levels, especially when first starting out. The number of superficial structures (nerves, blood vessels, muscles and bones) in such close proximity, along with the potential for serious injury if handled incorrectly is understandably the reason that so many therapists cite for their concerns.

However it doesn't need to be so daunting. In the case of a massage therapist — and many other types of physical therapists who deal largely with soft tissue treatment — the important things to know are:

• How to safely assess the Cx spine
• When soft tissue treatments will be beneficial to the patient
• When to refer on to another therapist or for further investigations such as MRI scans, etc.

This article aims to simplify the method of assessment for any soft tissue therapist confronted with neck issues (or symptoms that are suspected to be arising from the neck) and then help to determine if soft tissue treatment is appropriate and may be beneficial to the patient or if a referral elsewhere is necessary.

Assessing the Cx spine

A full history of both the current problem and any related previous issues and medical history should first be taken before any physical examination occurs. This is important as it gives you clues as to potential causes and can indicate more serious, underlying conditions.

Look out for symptoms such as dizziness, nausea, severe pain at night, constant pain, unexplained weight loss, and previous history of cancer and migraines. These are all potential red flags for something more systemic.

Symptoms such as sensory disturbances (tingling or numbness) into the hands or forearms, shooting or burning pains, weakness or a lack of coordination may indicate nerve root compression, spinal cord or peripheral nerve injury. Also look out for what medications the patient is taking and if these could be responsible for the current symptoms.

Finally, find out when the patient feels his/her symptoms. Is it constant, intermittent or just occasional? Establish any positions or activities that aggravate the condition and whether it is worst first thing in the morning, or develops as the day goes on. All of this information can be used to help you determine the root cause of the issue and the potential for something more serious that needs further medical attention.

For example, a constant moderate-to-severe pain that cannot be relieved is a good case for referral to a doctor for further examination. Whereas a mild-to-moderate pain that increases as the day goes on when sitting at a workstation and eases after work hours suggests a postural issue, for which soft tissue treatment may well be suitable.

Following the subjective assessment, a physical (objective) examination can be undertaken:

1. Observe

Look at the head, neck, shoulders and thoracic spine for any abnormalities in alignment, posture, muscle tone, etc. This should be done with the patient seated or standing and undressed to the waist where possible (bras are fine for female patients).

2. Active range of motion (AROM)

Ask the patient to move his head in all directions as far as possible and to tell you if there is any increase in his symptoms. Observe how far he can move each way and which, if any, of the movements aggravate his condition.

It is also advisable to check the AROM of the thoracic spine and shoulder joints. Restrictions in the Tx spine can translate up to the Cx spine. Similarly, a reduced range of shoulder motion can affect the muscles which bridge between the shoulder and neck.

3. Offload the neck to shoulder muscles

To help determine if a limitation in AROM is due to soft tissue tension, simply take the weight of one arm (elbow bent to 90 degrees) and lift it up so that the shoulder elevates towards the patients ear. This reduces tension in the upper Trapezius, Levator Scapulae and Scalenes.

If the patient can now move the neck more freely, then chances are the problem is soft tissue tension, either fully, or at least in part.

4. Myotomes

Myotomes are a form of assessment used to try to determine if there is a neural element to the condition. The therapist asks the patient to resist her force in a number of directions to ascertain if the muscles being tested are receiving a full neural input.

For example, resisting shoulder abduction tests the C5 nerve root; Wrist extension tests C6; Elbow extension tests C7; and finger flexion tests C8. A positive test is recorded if the patient cannot resist the therapist's full force.

5. Passive range of motion (PROM)

To further differentiate between soft tissue and structural limitations in motion, assess the PROM. This is most effectively done in a supine laying position as the patient can fully relax the neck. Flex, rotate and laterally flex the neck, comparing the motion now, to the range he performed actively.

If PROM is greater than AROM, again soft tissue tension is likely to play a part. If PROM is full and pain-free, it may be the only cause of his symptoms. If PROM results in only a partial increase, or still produces pain, then there may be something more structural to consider. If there is no change, then it is highly likely that the restriction is coming from the joints in the spine.

6. Reflexes

Reflexes are usually tested using a reflex (or patella) hammer. This is a useful and inexpensive tool that can help determine neural involvement throughout the body. The reflexes referred to are involuntary muscular responses elicited by the hammer tapping a tendon. A positive response sees the muscle twitch immediately following the impact.

To determine where a cervical neural problem may be, the therapist may test the following most common reflexes: biceps tendon (elbow crease), C5; brachioradialis (forearm), C6; triceps tendon (posterior elbow), C7.

Bear in mind that no response in the muscle is not necessarily a positive test. Always test the other side, too, as some people simply have diminished reflex responses or "poor reflexes," and this lack of response is normal for them.

7. Palpation

Finally, palpate the soft tissues in the neck and shoulder region, feeling for increased tension and trigger points that may be the source of the patient's symptoms.

When to treat and when to refer on

My advice is simple. If you have any concerns that the patient's condition is something more than you can treat, then refer her either to her doctor, or to another therapist who specializes in this field. Often a chiropractor is a great place to start.

Research local professionals and make links with those in your area whom you can refer your patients on to when necessary. You may even get some referrals back the other way.

On the whole, it can be considered safe to treat a patient who:

• Raises no red flags during his subjective assessment
• Has no history of serious accident or traumatic injury to the area
• Has mild to moderate pain and disability levels
• Shows no sign of consistent or severe neural involvement (sensory disturbances; diminished reflexes or weakened myotomes)
• Displays signs of soft tissue tension being at least a part of her problem (PROM being greater than and producing fewer symptoms than AROM)

Once soft tissue treatment has commenced and patients return for second, third and even fourth visits, keep asking about their symptoms. Note any changes, be they positive or negative. If the patient has shown no sign of improvement within five regular treatments, now is the time to reconsider referring him on for further investigation.

Play to your strengths, know your limits

In conclusion, soft tissue therapy can be a great tool in the treatment of Cx spine conditions. Muscular and fascial tension is such a common problem in this area due to postural issues, muscle imbalances and stress.

In many cases, soft tissue treatments such as massage, trigger pointing, dry needling, ART and MET's are effective in easing or even eradicating a patients symptoms. But it is important to know how to recognize your limits.

Soft tissue therapists are not trained in the area of spinal manipulations or mobilizations. When a joint restriction or disc issue, for example, is the cause of a patient's pain, no amount of soft tissue work will solve the problem, and the patient will appreciate your honesty and professionalism in referring her on to someone more equipped to deal with her issue.