Table 1 Descriptions of the physical examination procedures and definitions for a positive test

Sharp Purser [13, 14]

This procedure screens for integrity of the transverse portion of the cruciform ligament and/or fracture of the Dens of C2 in the sagittal plane. Palpation of posterior movement of the head and relocation (“clunk”) of C1 on C2 is considered a positive test.

Unilateral C2 Spinous Kick Test [13, 14]

This procedure screens for the coupled rotation of C2 during cervical lateral bending. Palpation of C2 spinous rotation contralateral (away) from the direction of side bending is considered normal. A positive test is when the examiner palpates a lack of C2 spinous rotation during lateral bending to one side.

Bilateral C2 Spinous Kick Test (asymmetry criterion)

Same procedure as above but comparing the amount of C2 rotation from one side to the other. A positive test is when the examiner notes an asymmetry in the amount of contralateral C2 spinous movement (kick) during side-bending.

Flexion Rotation Test [13, 14]

With the neck in full flexion, the examiner passively rotates the head bilaterally. A positive test is when the examiner observes an asymmetry in amount of rotation side to side, or symptoms are provoked by rotation to one or both sides.

Unilateral Modified Lateral Shear Test [13, 14]

This procedure screens for integrity of the alar ligaments in the coronal plane. Palpation of lateral translation of the C1 transverse process in relationship to C2 is considered a positive test. i.e. a firm end feel during translation is considered a negative test and a unilateral loose or ‘mushy’ end feel is considered a positive test.

Bilateral Modified Lateral Shear Test (asymmetry criterion)

Same procedure as above but in this case, an assessment of asymmetry of end feel during lateral translation is considered a positive test.

Sub-occipital muscle palpation with verbal pain provocation

Patient report of tenderness or pain provocation during muscle palpation of the sub-occipital region is considered a positive test.

Sub-occipital muscle palpation for presence of taut bands without verbal pain provocation

Taut bands or tightness assessed by the therapist during palpation of sub-occipital muscles is considered a positive test. Patients were asked not to verbalize pain or tenderness during this procedure.

Facet joint mobility testing: mid-cervical and lower-cervical with verbal pain provocation

Patient report of pain or tenderness provoked during palpation of the facet joints in the mid and lower cervical spine is considered a positive test.

Facet joint mobility testing: mid- and lower-cervical segmental mobility without verbal pain provocation

An assessment by the therapist of restricted segmental mobility during palpation is considered a positive test. Patients were asked not to verbalize pain or tenderness during this procedure.