1. Drift Test A.

Patient extends the arms anteriorly with the shoulders flexed to 90 degrees with the elbows extended and the hands supinated and the eyes closed, and holds this position for 1 !"0 seconds #. Positi$e% &drift' ( the slow dropping of one of the patient)s arms in an inferior and lateral direction *. Positi$e associated with% Pathologies affecting the motor cortex and+or brain stem ,. -autant)s Test A. #ilateral test. Patient is seated or .tanding. Patient extends the arms forward and ele$ates them to shoulder le$el. The hands are supinated. The patient maintains this position for a few seconds. The patient closes the eyes, rotates the head to one side and hyperextends the nec/. The examiner obser$es for any significant drifting of the arms from their original position. #. Positi$e% &drift' ( the slow dropping of one of the patient)s arms in an inferior and lateral direction. 0eports of blurred or double $ision, di11iness, nausea or light headedness *. Positi$e associated with% 2ertebral, basilar, or carotid artery stenosis or compression D. 3xample% 4f this test is positi$e on the right, this would indicate $ertebral, basilar, or carotid artery stenosis or compression on the right side. ". #arre!5ieou .ign A. Patient is seated. Patient is instructed to rotate the head maximally from side to side. This is mo$ement is performed slowly at first and then accelerated until the patient)s tolerance is reached. #. Positi$e% 2ertigo, di11iness, $isual disturbances, nausea, syncope, and nystagmus. *. Positi$e is associated with% $ertebrobasilar insufficiency D. 6ote% 4f #arre!5ieou sign is present on the left, the finding would indicate $ertebrobasilar insufficiency on the right side. 7. Di11iness Test A. 8ollowing any positi$e $ertebral artery test the examiner should attempt to determine if symptoms of nystagmus, di11iness or $ertigo are due to $ertebral artery compromise or $estibular dysfunction. #. Patient stares straight ahead and maintains the head position while the examiner rotates the upper trun/, shoulders and cer$ical spine, holds for 1 !"0 seconds. #ilaterally performed.

*. Positi$e% .ymptoms of nystagmus, di11iness or $ertigo are reproduced D. Positi$e associated with% 2ertebral artery compromise . Arm 0olling Test A. #ilateral simultaneous test. The patient is instructed to bend both elbows and place the forearms parallel to each other. The patient is then instructed to rotate the forearms around each other for ! 10 seconds in both directions #. Positi$e% The arm contralateral to the cerebral lesion is still and the other arm rotates around it. *. Positi$e associated with% Pathologies affecting the motor cortex and+or brain stem 9. :eorge)s 8unctional ;aneu$er A. #ilateral test. Patient is instructed to rotate and extend the head and cer$ical spine to one side and then hold their breath. This position is held for 1 !"0 seconds. The examiner watches the patient)s eyes. The maneu$er is then repeated on the other side. #. Positi$e% Di11iness, nausea, blurred or double $ision, light headedness or other symptoms of $ertebral artery compromise. ;ay notice nystagmus in the patient)s eyes <in$oluntary eye mo$ement=. *. Positi$e is associated with% 2ertebral and or carotid artery compromise >. ?nderburg)s Test A. #ilateral test. Patient is standing and is instructed to outstretch the arms, supinate the hands, and close the eyes. #. Patient is then instructed to march in place and extend and rotate the head while continuing to march. *. Positi$e% 5oss of balance, dropping of the arms or pronation of the hands D. Positi$e is associated with% $ertebral, basilar or carotid artery stenosis or compression. @. DeAleyn)s Test A. #ilateral test. Patient is lying down in the supine position with the head off of the table. The examiner instructs the patient to hyperextend and rotate the head and hold this position for 1 !7 seconds. #. Positi$e% 2ertigo, blurred $ision, nausea, syncope, and nystagmus. *. Positi$e is associated with% 2ertebrobasilar circulation compromise 9. -allpi/e ;aneu$er

A. This maneu$er is an enhance DeAleyn)s test and must be performed with extreme caution. #. The patient is lying down in the supine position with the head off of the table. The examiner pro$ides support for the weight of the s/ull. *. The examiner brings the patient)s head into positions of full extension, rotation, and lateral flexion while the patient /eeps their eyes open. D. The test is then repeated on the other side. 3. The final part of the maneu$er consists of the allowing the patient)s head to hand freely off the table in extreme extension <hyperextension=. 8. Positi$e% 2ertigo, blurred $ision, nausea, syncope, and nystagmus. :. Positi$e is associated with% 2ertebrobasilar artery insufficiency 10. *er$ical *ompression Test A. Doctor applies axial compression superior to inferior on top of the patient)s head. *ompression is applied for a minimum of seconds. <*ompression narrows the $ertebral foramen= #. Positi$e% Pain radiates down the patient)s arm C. Positi$e is associated with% 4n general this indicates ner$e root irritation in the cer$ical spine. 5ocal painB foraminal encroachment. 0adicular pain B ner$e root pressure. D. 2ariations of this test% Axial compression is applied at the gi$en range of motion listed below% 1. 6eutral <co$ered abo$e= ,. 0otation

10a. Cac/son *ompression Test A. The patient)s head is laterally flexed in an attempt to approximate the ear to the shoulder <lateral flexion=. This position is held, and the examiner exerts downward pressure on the patient)s head <axial compression= for a minimum of seconds. #. Positi$e% Pain radiates down the arm of the affected side *. Positi$e associated with% 6er$e in$ol$ement from a space! occupying lesion <.D5=, subluxation, inflammatory swelling, and exostosis of degenerati$e Eoint disease, tumor, or disc herniation. 10b. ;aximum *er$ical *ompression Test A. #ilateral test. The patient is instructed to rotate and extend the head and nec/ and stare at a point on the ceiling. This is then repeated on the contralateral side. #. Positi$e% 0adiating arm pain in the extremity on the side of rotation *. Positi$e is associated with% *er$ical ner$e root irritation 10c. .purlings Test

A. Part 1 B Cac/sonFs type lateral flexion and slight extension with progressi$e pressure. #. Part , B <6DT to be performed if Part 1 is positi$e= $ertical light blow to top of head in neutral, G lateral bending ! both sides. ?se of this modification should not be a surprise to the patient <inform them first=. *. Positi$e% Part 1 B 0eproduces pain or paraesthesia on side of flexion or a collapse sign. DD 6DT P308D0; PA0T , 46 T-4. .4T?AT4D6. Part , B ner$e root irritation or other pain sensiti$e structures related to disc disease. D. Positi$e is associated with% Part 1 ( 428 *ompression, Part , ( 6er$e 0oot 4rritation, disc disease, or spondylosis 10d. 3xtension Test <*ompression= A. .eated, head extended to "0 degreesH apply pressure to top of the head. #. Positi$e% 0eproduces cer$ical or radicular pain or decreases pain *. Positi$e is associated with% 4ncreased pain B pathology of 428, Decreased pain B posterolateral disc defect 10e. 8lexion Test <*ompression= A. Patient is seated and examiner flexes patient)s head forward, then applies pressure downward on the head <axial compression=. #. Positi$e% 0eproduces cer$ical or radicular pain or decreases pain. *. Positi$e is associated with% 4ncreased pain B disc defect, Decreased pain B apophyseal Eoint inEury or pathology. <Apophyseal B A syno$ial Eoint between the arches of $ertebrae. .uch Eoints are not supplied with ner$es therefore an inEury may pro$ide no warning pain and the damage may go unnoticed=. 11. .houlder Depressor Test A. #ilateral test. 3xaminer laterally flexes the patient)s head and stabili1es it in this position. The examiner then depresses the shoulder on the opposite side of cer$ical lateral flexion for seconds. 0epeat on the other side. #. Positi$e% Arm pain on the side of shoulder depression *. Positi$e is associated with% *er$ical ner$e root irritation+tension, brachial plexus irritation #rachial Plexus Tension Test A. #ilateral test. That patient is seated. The patient fully ele$ates the shoulders through abduction to the end!point of Eoint play. The elbows are extended to a point Eust short of the onset of pain. The examiner supports the patient)s arms in this position. #. The patient externally rotates the shoulders to the end!point of Eoint play <or the onset of discomfort=, while the examiner supports

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the patient)s arms in this position. As the arms are supported in this position the patient flexes the elbows <puts their hands behind their head=. 4n addition, symptoms can be further increased by putting the cer$ical spine in flexion. *. Positi$e% 0adicular arm pain D. Positi$e is associated with% ?nspecified irritation of the brachial plexus and+or cer$ical ner$e roots, 6er$e root syndrome

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*er$ical Distraction Test A. 3xaminer applies axial traction on the patient)s cer$ical spine by placing inferior to superior force on the patient)s mastoid processes. Traction is applied for a minimum of seconds <traction widens the inter$ertebral foramen= #. Positi$e% 0adicular arm pain is relie$ed *. Positi$e is associated with% 6er$e root irritation in the cer$ical spine #a/ody)s .ign <reduce pain= A. The patient abducts and externally rotates the ipsilateral shoulder by mo$ing the hand toward the head on the affected side <This should raise the elbow to a height approximately le$el with the head=. #. The patient then places the hand of the affected arm on top of his head for seconds. *. Positi$e% The maneu$er places slac/ in the cer$ical ner$e roots and the brachial plexus. The patient)s chief complaint of arm pain will be reduced when the maneu$er is performed on the symptomatic side. D. Positi$e is associated with% *er$ical ner$e root compression E. Clinical Pearl Patients with moderate to severe radicular syndromes may present to the Doctor in the Bakodys Sign position because it is an antalgic pain relieving posture. 0e$erse #a/ody)s ;aneu$er <cause pain= A. #ilateral test. The patient is instructed to place the hand of his unin$ol$ed arm on top of his head. 0epeat on the symptomatic side. #. Positi$e% ;aneu$er places pressure on the neuro$ascular bundle as it passes under and around the pectoralis minor muscle. The patient)s chief complaint of arm pain will be reproduced when the maneu$er is performed on the symptomatic side. *. Positi$e is associated with% Thoracic Dutlet .yndrome, unspecific irritation of the ner$e roots of the brachial plexus

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0oo)s test <.tic/ Iem up= A. #ilateral simultaneous test. .eated position. Patient is instructed to abduct the arms laterally to 90 degrees and then begin closing and opening the hands rapidly. This test is performed for " minutes. #. Positi$e% Affected arm wea/ens and patient experiences numbness, tingling, wea/ness or other symptoms of thoracic outlet syndrome and may not be able to complete the test. *. Positi$e is associated with% Thoracic Dutlet .yndrome Adson)s Test A. #ilateral test. 3xaminer palpates the patient)s radial pulse of in$ol$ed side. The strength of the pulse is noted. The patient is then instructed to rotate and extend the head toward the effected arm+shoulder. The examiner externally rotates and extends the shoulder. The patient is instructed to ta/e a deep breath and hold it. The examiner assesses the patient)s radial pulse for 1 !"0 seconds. 0epeat on other side. #. Positi$e% 5oss or wea/ening of the radial pulse *. Positi$e is associated with% .calene muscle irritation+entrapment of the neuro$ascular bundle on the symptomatic side causing a thoracic outlet syndrome or cer$ical rib syndrome -alstead ;aneu$er A. A. #ilateral test. Patient is seated with arms at the sides. 3xaminer palpates the patient)s radial pulse bilaterally. The strength of the pulse is noted. The examiner applies downward traction on the affected arm+shoulder while the patient hyper! extends the nec/. The examiner assesses the patient)s radial pulse for 1 !"0 seconds. 0epeat on other side. 6ote% 4f the test is negati$e <the pulse does not disappear=, the test is repeated with the patient)s head rotated to the opposite side. #. Positi$e% 5oss or wea/ening of the radial pulse *. Positi$e is associated with% .calene muscle irritation+entrapment of the neuro$ascular bundle on the symptomatic side causing a thoracic outlet syndrome 3den)s Test A. A. #ilateral test. 3xaminer palpates the patient)s radial pulse bilaterally. The strength of the pulse is noted. The patient is then instructed to ta/e a deep breath, hold it and pull his shoulders bac/ protruding the chest. <Puff out chest= The patient is then instructed to flex the chin to the chest. The position is held for 1 ! "0 seconds while the examiner monitors the radial pulses. #. Positi$e% 5oss or wea/ening of the radial pulse

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*. Positi$e is associated with% .calene muscle irritation+entrapment of the neuro$ascular bundle on the symptomatic side causing a thoracic outlet syndrome ,0. Jright)s Test <-yperabduction test= A. #ilateral test. Patient is seated with both arms hanging at the sides. The examiner palpates the radial pulse of the affected arm. The examiner abducts the affected arm to 1@0 degrees. The examiner notes the angle of abduction at which the radial pulse on the affected side diminishes or disappears. The angle is compared with the angle obtained on the unaffected side. #. Positi$e% 0adial pulse<s= decrease or disappear Eust abo$e 90 degrees 6ote% !" the non a""ected limb demonstrates radial pulse dampening o" cessation at the same appro#imate degree o" abduction as the a""ected side$ the test is not positive. *. Positi$e is associated with% Thoracic outlet syndrome due to compression of the neuro$ascular bundle where is passes under the pectoralis minor muscle Allen)s Test <hand= A. #ilateral test. Patient is seated with the elbow of the affected arm flexed and the forearm supinated. The examiner occludes the patient)s radial and ulnar arteries using both hands <thumb of each hand wor/s well=. The patient is then instructed to repeatedly open and close the hand while the doctor maintains arterial occlusion. The patient then opens the hand, and the examiners opens one artery, radial or ulnar. 8illing time of the hand is recorded. #. Positi$e% *irculation fails to return in seconds *. Positi$e is associated with% 0adial and+or ?lnar arterial occlusion 5hermitte)s Test sharp, shoc/, electric sensation ( board Kuestion A. Patient is seated. The head and nec/ are passi$ely flexed toward the patient)s chest. #. Positi$e% 8lexion of the cer$ical spine causes a sharp, shoc/ or electric li/e sensation in one or more of the extremities *. Positi$e is associated with% .pinal cord pathology, ;yelopathy of the *er$ical spine .oto!-all Test A. The patient is supine. The examiner applies steady pressure to the patient)s sternum. The examiner then lifts the patient)s head flexing the cer$ical spine and approximating the patient)s chin to chest.

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#. Positi$e% Pain experienced in cer$ical and+or thoracic spine or in unable to perform the maneu$er 6ote% 4f a reflex flexion of the /nees and thighs is produced <Aernig)s or #rud1ins/i)s sign=, this suggests meningitis *. Positi$e is associated with% .ubluxation, Disc lesion, sprain or strain, $ertebral fracture, or meningeal irritation ,7. 2alsal$a)s ;aneu$er A. The patient is seated. Patient is instructed to ta/e a deep breath and hold it. Jhile holding the deep breath, the patient bears down to create greater intra!abdominal pressure. #. Positi$e% 4ncreased pain *. Positi$e associated with% .pace occupying lesion <.D5=H li/e a herniated disc, tumor, or osteophytes DeEerine)s .ign A. *oughing, snee1ing, and straining during defecation may aggra$ate radiculitis symptoms. This aggra$ation results from the mechanical obstruction of spinal fluid flow. DeEerine)s sign is present when one of the following exists% herniated or protruding inter$ertebral disc, spinal cord tumor, or spinal compression fracture. The course of the radiculitis helps identify the location of the lesion. #. Positi$e% Pain when coughing, snee1ing, or straining during defecation *. Positi$e associated with% .D5 that is creating neurologic compression 6aff1iger)s test na1i A. Jith the patient seated comfortably, the examiner occludes the Eugular $eins bilaterally for "0!70 seconds. The patient is instructed to cough deeply. #. Positi$e% Pain *. Positi$e associated with% .D5 in the cer$ical spine, .ign is always positi$e in the presence of cord tumors, particularly spinal meningiomas. 6ote% %his test is contraindicated "or a geriatric patient$ and e#treme care should be taken when per"orming this test on anyone suspected o" having atherosclerosis. D)Donoghue)s maneu$er A. Jith the patient seated put the cer$ical spine through resisted range of motion, then through passi$e range of motion. #. Pain during resisted range of motion <isometric muscle contraction= signifies muscle strain *. Pain during passi$e range of motion signifies a ligament sprain

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D. This procedure can be applied to any Eoints of series of Eoints do determine a ligamentous or muscular in$ol$ement. ,@. Alar 5igament Test A. ?seful for determining Alar ligament stability. #. Patient is supine. The examiner will hold the patient)s head with one head and hold the *, with a pinch grip at the spinous process and lamina. Attempt a side!to!side shearing stress with the head against the *,. *. Positi$e% 3xcessi$e laxity in side!to!side mo$ement. D. Positi$e is associated with% .tretched or torn Alar ligaments. ,9. 0ust)s .ign A. 4f the patient spontaneously grasps the head with both hands when lying down or when arising from a recumbent position, this is a positi$e sign that indicates se$ere sprain, rheumatoid arthritis, fracture, or se$ere cer$ical subluxation <atlantoaxial instability=. "0. *hest 3xpansion Test will not ha$e to perform this one A. The chest diameter is measured at the le$el of the 7th intercostal space. The measurement is ta/en as the patient exhales maximally and then again when the patient inhales deeply. #. The normal difference between inspiration and expiration is .> cm ( >.9, cm <1. ( " inches=. *. A positi$e would indicate the existence of an/ylosing spondylitis. D. This test is a sensiti$e indicator of early in$ol$ement of the costo$ertebral Eoints in A.. This test is usually positi$e before the patient reali1es a change in chest comfort. "1. 8irst Thoracic 6er$e 0oot Test A. Patient is seated. Patient abducts arm to 90 degrees and pronates arm <palms down=. Patient flexes elbow to 90 degrees. Patient then pronates forearm+hand to 90 degrees. The patient then places their hand behind the head. #. Positi$e% .capular pain on the affected side *. 4ndicates ner$e root compression at T1. ",. Passi$e .capular Approximation Test A. Patient is seated or standing. 3xaminer passi$ely approximates the patient)s scapulae <Push the shoulders together ( grab outer upper arms around deltoid=. #. Positi$e% .capular pain on the affected side. *. 4ndicates a compression syndrome at the T1 or T, ner$e root. "". Adam)s Position <.eated or .tanding= <need to see bare bac/=

A. Jith the doctor behind the patient, the doctor obser$es for any spinal asymmetry, scapular winging, or chest rotational deformity. 8or posterior Adam)s position, the patient flexes forward at the waist, the arms are allowed to hang toward the floor and the hands are placed together in prayer position. Doctor obser$es patient)s spine for deformity <if any=.8or anterior Adam)s position, the patient flexes forward at the waist, the arms are allowed to hang toward the floor and the hands are placed together in prayer position. 4n addition the bac/ is allowed to round and the cer$ical spine to flex as well. The examiner, who is anterior to the patient, obser$es the spine for deformity <if any=. #. *linical .ignificance% ! if the patient has a . or * type scoliosis the cur$ature may straighten when the spine flexes forwardLif it does, it is a negati$e sign and e$idence of functional scoliosis ! A true positi$e is when the scoliosis does not impro$e after flexing forward <.tructural=

"7. Adam)s 5ateral 8lexion A. Patient is standing. The patient)s spine will need to be $isible. 4nstruct the patient to lateral flexion to one side without rotation of the spine. 0epeat the lateral flexion on the other side. #. Positi$e% *on$ex side of scoliosis will not allow the thoracic spine to cur$e into a conca$e posture. *. Positi$e is associated with% .tructural scoliosis made e$ident. " . .chepelmann)s .ign A. The patient is seatedH the patient fully abducts the shoulders and brings the hands o$erhead. The patient flexes the thoracic spine laterally. This test is performed bilaterally. #. *linical .ignificance% ! Pain elicited on the side of flexion <conca$e= indicates intercostal neuritis ! Pain elicited on the con$ex side indicate intercostal myofascitis ! .chepelmann)s .ign identifies rib integrity ! This test pro$ides an efficient method for locali1ing rib inEury "9. 8orestier)s #owstring .ign A. Patient is standing. 3xaminer must be able to see the patient)s bac/ musculature, so the patient must remo$e their shirt. #. .tanding patient performs side bending and re$eals ipsilateral tightening and contracture of the paraspinal musculature. *. 6ormally, the contralateral musculature demonstrates tightening.

D. Test is significant for An/ylosing .pondylitis <A.=. 4f pt has A., then they will not be able to bend 3. This test also indicates strain and inter$ertebral disc in$ol$ement, any loss of symmetric motion may be examined further. A good history will help discriminate. ">. .ternal *ompression Test A. Jhile the patient is in the supine <laying on bac/= position, the examiner exerts downward pressure on the sternum </nife edge=. #. 5ocali1ed pain at the lateral border of the ribs indicates a rib fracture. "@. .pinal Percussion Test A. Patient is seated or standing. Patient)s head is flexed forward, percussion of spinous processes and associated musculature with reflex hammer. #. Positi$e% 5ocal pain or radicular pain *. 5ocal pain B Possible fracture, 0adicular pain B possible disc lesion, other possible causes B sprain+strain "9. #ee$or)s .ign A. Patient is supine. Abdominal muscles are palpated and the position of the umbilicus is established. The examiner fixes the patients legs to the table and the patient then performs a partial sit!up with hands folded across the chest. The examiner notes any drift of the umbilicus <belly button=. #. 6ormally, upper and lower abdominal muscles contract eKually and the umbilicus does not mo$e or drift. *. Jhen lower abdominal muscles alone are wea/ened, the umbilicus will be drawn upward by the contracture of the intact upper musculature. D. 4ndicates, lower abdominal wea/ness and myelopathy associated with the T10 spinal le$el. 70. Anghelescu)s .ign A. Patient is supine. 3xaminer notes any antalgic <free of pain naturally= li/e positions. Patient attempts to raise the thoracic spine off the table <shoulders and feet remain on table=. #. 4nability to hyperextend the spine indicates a disease process, and may suggest tuberculous spondylitis <primarily effects the thoracic and lumbar spine=. 71. Amoss)s .ign A. Patient can be either supine or in a side!lying position. The patient will then wrap their arms around their body. The patient then attempts to rise from a supine or side!lying position. #. .ign is present when either action elicits a locali1ed thoracic or thoracolumbar spinal pain.

*. ;ay suggest A., se$ere sprain, or 42D syndrome. 7,. 0ib ;otion Test A. Patient is supine. As the patient inhales and exhales, the AP mo$ement of the ribs is palpated, and any restriction is noted. #. 0ib abnormalities during exhalation suggest an ele$ated rib <lowest rib= while during inhalation suggests a depressed rib <uppermost rib=. *. 3xample of .DAP note% 0ib motion for ribs !> on the right is inhibited during inhalation, suggesting a depressed th rib. During exhalation, this would suggest an ele$ated >th rib. 3$ans 4llustrated Drthopedic Test ( the boo/ that he <and the #oard= uses. D.*3 is next Thursday, o$er of the abo$e