Sunteți pe pagina 1din 10
ARTICLE IN PRESS Manual Therapy 11 (2006) 321–330 www.elsevier.com/locate/math Technical and measurement report

ARTICLE IN PRESS

ARTICLE IN PRESS Manual Therapy 11 (2006) 321–330 www.elsevier.com/locate/math Technical and measurement report

Manual Therapy 11 (2006) 321–330

ARTICLE IN PRESS Manual Therapy 11 (2006) 321–330 www.elsevier.com/locate/math Technical and measurement report

Technical and measurement report

Inter-tester reliability of passive intervertebral and active movements of the cervical spine

Sara R. Piva a, , Richard E. Erhard b,c , John D. Childs d , David A. Browder d

a School of Health and Rehabilitation Sciences, Department of Physical Therapy, University of Pittsburgh, 6035 Forbes Tower, Pittsburgh, PT 15260, USA b University of Pittsburgh Medical Center Health System’s Spine Specialty Center, USA c School of Health and Rehabilitation Sciences, Department of Physical Therapy, University of Pittsburgh, USA d Department of Physical Therapy, Wilford Hall Medical Center, San Antonio, TX, USA

Received 4 February 2004; received in revised form 1 August 2005; accepted 21 September 2005

Abstract

Measurements of active range of motion (AROM) and passive intervertebral movements (PIM) of the cervical spine are frequently used for patients with neck pain. However, there is a paucity of studies that investigate the psychometric pro- perties of these measurements. Objectives of this study were to: (1) determine the inter-tester reliability of PIM, AROM, and the effects of AROM on symptom provocation; (2) establish the minimal detectable change (MDC) in cervical AROM; and (3) determine the association between AROM and disability. Thirty subjects (age 41 7 12) with neck pain participated in this study. Two masked examiners performed the measurements during the same testing session. PIM was assessed manually and recorded as hypomobile or normal. AROM was measured in degrees with a gravity goniometer. The effect of AROM on patient’s symptoms was recorded as no change, decreased, increased, centralization, or peripheralization. Measures of AROM had moderate to substantial reliability (.78–.91) and resulted in a MDC adequate for clinical use (from 91 to 161 ). The effect of AROM on symptom provocation resulted in Kappa values that ranged from slight to substantial (.25–.87). Measures of PIM resulted in substantial and moderate reliability of assessing occipital–atlas mobility, tenderness of the transverse processes of atlas, and symptom provocation during PIM testing of the lower cervical segments. Fair Kappa values were observed during judgment of mobility in the C2 segment and symptom reproduction during PIM of C2 and C5. The additional PIM had Kappa values that ranged from none to slight. Low prevalence of positive findings likely resulted in an artificial deflation of the Kappa statistic during some PIM measures. Measures of AROM in saggital and transverse planes were associated with disability scores (r ¼ :43 and : 40; respectively). Findings are relevant to the planning of future studies to establish the criterion validity of these tests to guide the selection of interventions and establish prognosis in patients with neck pain. r 2005 Elsevier Ltd. All rights reserved.

Keywords: Consistency; Measurement; Neck pain; Repeated measures study

1. Introduction

Measurements of active range of motion (AROM) and passive intervertebral movements (PIM) of the cervical spine are routinely used as part of the physical

Corresponding author. Tel.: +1 412 383 6712; fax: +1 412 383 6629. E-mail address: srpst24@pitt.edu (S.R. Piva).

1356-689X/$ - see front matter r 2005 Elsevier Ltd. All rights reserved.

examination of patients with neck pain. Tests of AROM and PIM are used to identify impairment in motion and possible segmental level that may be the source of the patient’s complaint.(Magee, 1997) Measurements of AROM are performed to determine limitations in motion, patient’s willingness to move, and to identify the range of movement in which the patient reports symptoms. During AROM examiners note the quantity, quality, and provocation of the patient’s complaints in

322

ARTICLE IN PRESS

S.R. Piva et al. / Manual Therapy 11 (2006) 321–330

each direction of movement. (Magee, 1997) The effect of each movement on the patient’s symptoms is also useful

to guide treatment decisions (i.e. knowing whether the

symptoms increase or decrease or whether the symptoms centralize or peripheralize, etc.) (McKenzie, 1990; Werneke and Hart, 2001). It helps clinicians understand which movements should be avoided and which move- ments should be used during treatment. For example, centralization of the patient’s symptoms during flexion provides some indication that exercises in a flexed position may be beneficial. PIM are performed to assess the amount of motion available at each spinal segment and the provocation of symptoms during movement of each segment of the

cervical spine. PIM are necessary for normal physiologic

a range of motion to occur. (Maitland, 1986) It is

believed that the decreased PIM motion (hypomobility), which may be caused by muscle spasm or ligamentous tightness, may be associated with neck dysfunction. (Erhard, 1996; Childs et al., 2003) In general, previous studies examining the reliability of AROM measurements of the cervical spine have demonstrated acceptable levels of reliability. (Jordan, 2000; Mannion et al., 2000; Petersen et al., 2000; Solinger et al., 2000) However, many of these studies investigated reliability in asymptomatic individuals, (Youdas et al., 1991; Nilsson, 1995; Hole et al., 2000) others performed inappropriate statistics to estimate reliability, (Kadir et al., 1981; O’Driscoll and Tomen- son, 1982; Capuano-Pucci et al., 1991) some used only visual estimation of movements, (Viikari-Juntura, 1987; Pool et al., 2004) and some used measurement tools not practical for clinical use (Rheault et al., 1992). Few studies used simple measurement tools such as the universal goniometer or gravity goniometer (Tucci et al., 1986; Youdas et al., 1991). Furthermore, these studies have not reported the precision or the error associated with these measurements. A systematic review that evaluated 21 studies that assessed the reliability of tools to measure cervical range of motion concluded that more rigorous studies were necessary (Jordan, 2000). A more recent study reported acceptable reliability for measures of cervical AROM when a gravity goniometer was used and, to our knowledge, this is the only study that determined the error associated with their measure- ments (Wainner et al., 2003). Not many studies have investigated the reliability of assessing PIM. To date, only one study investigated the inter-observer reproducibility of the patient’s pain response to movement, and a small number of studies have reported on the reliability of PIM. Pool et al. (2004) performed a study in which an 11-point numerical rating scale was used to report pain response during movement. In addition to assess the reliability of patient’s pain response, Pool et al. studied the consis- tency of assessing PIM from the occiput to T2. They

reported Kappa values from .09 to .63. However, definitions of the assessment techniques were not clear. They only described that movements between the occiput and atlas used a flexion technique, assess- ment of atlas/axis mobility used a rotation technique, and segments from C2 to T2 included fixation of the lower segmental level and lateral flexion to the right and to the left (Pool et al., 2004). Fjellner et al. (1999) studied PIM on normal healthy subjects. Therefore, their results may not apply to patients with neck pain. Smedmark et al. (2000) studied inter-tester reliability in assessing PIM of four tests of the cervical spine: C1/C2 rotation, C3/C4 lateral flexion, C7 flexion/extension, and movement of the first rib. They reported Kappa values from .28 to .43. In addition to further investigate the reliability of testing AROM, PIM, and symptom provocation during movement, it would be helpful to determine if measures of AROM are associated with measures of disability, thus helping to establish validity for these measure- ments. Therefore, the objectives of this study were to: (1) determine the inter-tester reliability of PIM, AROM, and the effects of AROM on symptom provocation; (2) establish the minimal detectable change (MDC) in cervical AROM; and (3) determine the association between AROM and disability.

2. Methods

This study utilized a single group repeated measures design.

2.1. Subjects

This study consisted of consecutive patients referred to the University of Pittsburgh Medical Center Health System’s Spine Specialty Center with a primary com- plaint of neck pain. The following inclusion criteria were used: (1) age between 18 and 75 years; (2) presence of symptoms in the neck, scapula, or head areas observed on the pain diagram; (3) less than 60% score on the Neck Disability Index (NDI) (Vernon and Mior, 1991). Based on our clinical experience, scores above 60% indicate that the patient is experiencing a high level of disability in which repeating the examination procedure for reliability purposes could excessively exacerbate the patient’s symptoms. Patients were excluded if the neck pain was associated with inflammatory or congenital anomalies, presence of dizziness, or neurological signs and symptoms. This study was approved by the University of Pittsburgh Institutional Review Board, and all subjects provided informed consent prior to participate in the study. Thirty subjects with neck pain agreed to participate.

ARTICLE IN PRESS

S.R. Piva et al. / Manual Therapy 11 (2006) 321–330

323

2.2. Measure of disability

The NDI was used to quantify the level of disability. The NDI is a reliable, valid and frequently used condition-specific disability scale for patients with neck pain (Vernon and Mior, 1991; Stratford et al., 1999). The disability score from the NDI was used in the assessment of the relationship between disability and AROM.

2.3. Measurements of AROM and PIM

2.3.1. Cervical AROM Extension, flexion, rotation in full flexion, left and right lateral bending, and left and right rotation were tested in the order as described. Active movements were measured in degrees using a gravity goniometer (MIE Medical Research Ltd, Leeds, UK). Measures of extension, flexion, rotation in full flexion, and lateral bending were performed with the patient seated on an examination table. Before initiating measurements, subjects were asked to ‘‘sit up and look straight ahead’’. Measurement of rotation was performed with the patient positioned in supine. Prior to the measurements, the gravity goniometer was zeroed by placement on a horizontal surface. Extension was measured by placing the gravity goniometer on the top of the patient’s head in the saggital plane. Patients were asked to bend the head backward as far as possible (Fig. 1). Flexion was measured with the gravity goniometer in the same position as for the extension measure- ment. The gravity goniometer was not removed from the patient’s head during extension and flexion. Patients were asked to bend the head forward as far as possible and try to touch the chest with the chin (Fig. 2). Rotation in full flexion was used to grade the atlantoaxial rotation. Patients were in full neck flexion and the gravity goniometer was positioned on the back of patient’s head in the frontal plane. Patients were asked to rotate the head to the left and right as far as possible (Fig. 3). Lateral bending was measured with the gravity goniometer in the frontal plane on the top of the patient’s head. To measure lateral bending, patients were asked to touch the left and right ear to the left and right shoulder respectively. Rotation was measured with the patient in the supine position with the head resting on a pillow. To allow pure axial rotation, the patients were permitted to lift their head of the pillow before rotation. The gravity goniometer was in the transverse plane on the top and midline of the forehead. To measure rotation, patients were asked to rotate the head to the left and after to the right as far as possible (Fig. 4).

left and after to the right as far as possible ( Fig. 4 ). Fig. 1.

Fig. 1. Measurement of active neck extension.

as far as possible ( Fig. 4 ). Fig. 1. Measurement of active neck extension. Fig.

Fig. 2. Measurement of active neck flexion.

324

ARTICLE IN PRESS

S.R. Piva et al. / Manual Therapy 11 (2006) 321–330

2.3.2. Effect of movement on symptoms The effect of AROM on participant’s symptoms was recorded such as: no effect, increases symptoms, decreases symptoms, centralizes symptoms, or periph-

decreases symptoms, centralizes symptoms, or periph- Fig. 3. Measurement of active neck rotation in full

Fig. 3. Measurement of active neck rotation in full flexion.

eralizes symptoms. Centralization is the patient report that the neck movement has caused the symptoms to move from an area more distal or lateral in the arms or shoulder girdle to a location more central or near the midline position in the cervical spine. Alternatively, peripheralization is the patient’s report that the neck movement moved the symptoms from an area more proximal in the cervical spine to an area more distal or lateral (McKenzie, 1990; Werneke and Hart, 2001).

2.3.3. Cervical PIM PIM testing was used to qualitatively determine the amount of motion that occurred at each spinal segment. PIM for the cervical spine involves the palpation of each motion segment during passive movement of the head and neck. Measurements were performed with the patient in the supine position and in the order described. Mobility was recorded as: (1) normal; or (2) hypomo- bile. Pain reproduction during each movement was recorded as: (1) pain; (2) no pain. Atlanto-occipital joint—lateral glide: The examiner held the patient’s head with a neutral relation- ship between the occiput and atlas and performed a left lateral-glide of the occiput on atlas, followed by a right lateral-glide (Erhard, 1996; Magee, 1997). If decreased mobility was noted to one side compared to the opposite side, the test was considered positive for hypomobility. Atlanto-occipital joint—lateral displacement of axis:

The examiner stabilized the axis by placing the left thumb on the left side of the spinous process of the axis. Then the examiner used the right hand to laterally bend the head to the right. The test was then repeated to the

bend the head to the right. The test was then repeated to the Fig. 4. Measurement

Fig. 4. Measurement of active neck rotation in supine.

ARTICLE IN PRESS

S.R. Piva et al. / Manual Therapy 11 (2006) 321–330

325

opposite side (Erhard, 1996). If decreased mobility was noted to one side compared to the opposite side, the test was considered positive for hypomobility. Tenderness over the transverse processes of atlas: The examiner gently palpated the transverse processes of the atlas and recorded the presence of symptoms on either side as positive. Atlanto-axial joint—full flexion: The examiner sup- ported patient’s head with both hands and passively moved the patient’s neck into maximal flexion. While maintaining this position, the patient’s head was rotated first to the left and then to the right (Erhard, 1996). If the rotation to one side was decreased compared to the opposite side, the test was considered positive for hypomobility. Atlanto-axial joint—full lateral bending: The examiner passively moved the patient’s neck into end range of right lateral-bending. While maintaining this position, the patient’s head was rotated to the left. The test was then repeated to the opposite side (Erhard, 1996). If the rotation to one side was decreased compared to the opposite side, the test was considered positive for hypomobility. Mid and lower cervical: The examiner stood at the head of the examination table and used the abdomen to exert a constant pressure against the apex of the patient’s skull to stabilize the head but allow free neck movements. Each spinal level beginning at C2 was glided laterally to the left and right. The examination progressed inferiorly to C6. If decreased mobility was noted to one side compared to the opposite side, the test was considered positive for hypomobility (Erhard, 1996; Hertling and Kessler, 1996; Magee, 1997).

2.4. Procedures

Patients attended one testing session lasting approxi- mately 20 min. During the testing session, each patient remained inside an examination room. To warrant examiner’s masking, the two examiners entered the examination room independently, performed and re- corded the measurements, and then left the room. The assessment results were not shared with the other examiner. To minimize the possibility that the PIM by the first examiner would cause a true change in the patient’s symptoms and restriction in motion, both examiners performed the AROM tests before the PIM. Therefore, each examiner entered the room twice. The AROM and PIM testing were always performed in the same order. The order of the examiners was varied for each new patient (i.e. examiner 1 performed the exam first for subject 1; examiner 2 performed the exam first for subject 2, and so on). Examiners were trained in manual therapy and had different levels of experience (10 and 2 years, respectively). Examiners and investiga-

tors met once during a 2-h session before data collection to review operational definitions and practice the procedures to ensure standardization.

2.5. Sample size estimation

The sample size was calculated a priori using SamplePower TM statistical software (SPSS Inc., Chica- go, Illinois) (SPSS, 1998) based on the calculation of Cohen Kappa coefficients on a dichotomous variable (i.e. hypomobile or normal). To ensure sufficient statistical power to achieve a lower bound of the 95% confidence interval for Kappa of 0.30, assuming Kappa would be equal to 0.60, we would need a sample size of 30 subjects (Cohen, 1988).

2.6. Data analysis

Descriptive statistics, including frequency counts for categorical variables and means and standard deviations for continuous variables were calculated to summarize the data. Cohen’s Kappa statistic and the associated 95% confidence intervals were used to calculate inter-tester reliability of the classifica- tion of mobility and presence of pain during the PIM, and the effect of AROM on the patient’s symptoms (Cohen, 1960; Simel et al., 1991). The agreement of the effect of AROM on the patient’s symptoms was based on both examiners placing the patient in the same category of the five possible ones (e.g. both say increases symptoms; or both say centralizes symptoms). Intra-class correlation coefficient (ICC), formula 2,1, and its 95% confidence interval were calculated to determine the inter-tester reliability for measurements of cervical AROM (Shrout and Fleiss, 1979; Simel et al., 1991). Values less than 0.10 indicate virtually no agreement; 0.11–0.40 indicate slight agree- ment; 0.41–0.60 indicate fair agreement; values between 0.61 and 0.80 indicate moderate agreement; and values greater than 0.81 indicate substantial agreement (Shrout, 1998). The results of the reliability analyses were used to calculate the standard error of measurement (SEM) and the MDC. The SEM was calculated as sd O 1 r, where r is the test–retest reliability coefficient and sd is the standard deviation of the combined scores of both examiners (Stratford and Goldsmith, 1997). The MDC was calculated as 1.96 O 2 SEM (Portney and Watkins, 1993). In this formula 1.96 is the standard normal score associated with a two-tailed 95% confidence interval and the O 2 is included to reflect the fact that there is measurement error associated with both the first and second repeated measures when calculating test–retest reliability. The Pearson correlation coefficient was calculated to determine the association between the NDI scores and AROM.

326

ARTICLE IN PRESS

S.R. Piva et al. / Manual Therapy 11 (2006) 321–330

3. Results

Demographic characteristics of the 30 subjects who participated in the study are reported in Table 1. Means and standard deviations, ICC values, the corresponding SEM and MDC values of AROM measurements are depicted in Table 2. The ICC values for measures of AROM ranged from moderate to substantial (from .78 to .91) and the respective MDC values varied from 9 1 to 16 1 . Kappa values for symptom reproduction during AROM are also depicted in Table 2. Kappa values of right rotation in flexion and left lateral bending were only slight. Symptom reproduction during

Table 1 Summary statistics of participants

Number ¼ 30

Neck pain patients

Gender

60% female

Age

Median

41.5

Mean (SD)

41 (12)

Race

87% White

7% Afro-american

3% Hispanic

3% Asian

Pain (Numeric pain scale)

Median

4.5

Mean (SD)

4.7 (2.4)

NDI

Median

20

Mean (SD)

24.3 (14.8)

Gender and race data is reported as a percentage of participants,

whereas age, pain, and Neck Disability Index (NDI) data are reported

as median, mean, and standard deviation (SD).

flexion had a substantial Kappa value (.87). The additional Kappa values of symptom reproduction were moderate (ranged from .65 to .76). Kappa values, percentage of agreement, and preva- lence of positive findings for measurements of PIM are reported in Table 3. Kappa values for PIM were substantial for occipital-atlanto joint hypomobility tested with side glides (.81) and tenderness over the transverse processes of atlas (.83). Kappa values were moderate for symptom reproduction during test of atlanto–axial joint in full lateral flexion (.61) and symptom reproduction during PIM of C4 and C6 (.65 and .76, respectively). Fair Kappa values were observed during judgment of mobility in the C2 segment (.46) and symptom reproduction during PIM of C2 and C5 (.42 and .55, respectively). Other PIM tests demonstrated slight or no agreement. Increased levels of disability on the NDI were fairly associated with decreased total saggital plane AROM (flexion+extension) (r ¼ : 43) and total transverse plane AROM (left rotation+right rotation) (r ¼ : 40).

4. Discussion

An important element of the validity of measure- ments, and the subsequent ability to accurately interpret these measurements, relies on the evidence of satisfac- tory reliability and measurement error (Hains et al., 1998). Poor reliability and high levels of measurement error reduce the usefulness of a test and limit the extent to which test results can be generalized (Hains et al., 1998). This study has shown that measures of cervical

Table 2 Means, standard deviations, ICC, SEM and MDC values for measures of AROM; and Kappa values, and percentage of agreement between raters for symptom reproduction during AROM

N ¼ 30

Mean (SD) a (degrees)

ICC b (95% CI) AROM

SEM c (degrees)

MDC d (degrees)

Kappa (95% CI) symptom reproduction

Agreement

Extension

48 (15)

.86 (.73: .93) .78 (.59: .89)

5.6

16

.65 (.54: .76) .87 (.81: .94) .69 (.59: .78)

83%

Flexion

60 (13)

5.8

16

93%

L

e rotation in

39

(10)

.89 (.78: .95)

3.2

9

83%

flexion

 

R

f

rotation in

39

(13)

.78 (.60: .89)

5.3

15

.25 (.12: .39)

63%

flexion

 

L

lateral bending

39 (11)

.85 (.70: .92)

4.2

12

.28 (.15: .41) .75 (.66: .84) .74 (.64: .84) .76 (.67: .84)

63%

R

lateral bending

41 (11)

.87 (.75: .94)

3.7

10

87%

L

rotation

68 (13)

.91 (.82: .96)

4.1

11

87%

R

rotation

68 (14)

.86 (.74: .93)

4.8

13

87%

a Means and SDs are based on rater 1 whilst the SEM and MDC are based on the combined raters’ scores.

b Intraclass correlation coefficient.

c Standard error of measurement.

d Minimum detectable change.

e Left.

f Right.

ARTICLE IN PRESS

S.R. Piva et al. / Manual Therapy 11 (2006) 321–330

 

327

Table 3 Kappa values, percentage of agreement between raters, and prevalence of positive tests for measurements of PIM

 
 

Kappa (95% CI)

Agreement

Prevalence

Occipital-atlanto joint—lateral glide

Mobility

.81 (.72: .91) .32 (.15:. 49) .35 (.08: .62) .35 (.15: .55) .83 (.74: .92) .21 (.08: .34) .36 (.24: .49) .30 (.17: .43) .61 (.5: .72) .46 (.33: .59) .42 (.28: .56) .25 (.12: .38) .29 (.16: .43) .27 (.13: .40) .65 (.54: .76) .18 (.03: .33) .55 (.43: .67) .07 ( .34: .20) .76 (.64: .87)

93%

27%

Pain

77%

27%

Occipital-atlanto joint—lateral displacement of axis

Mobility

90%

10%

Pain

83%

17%

Tenderness over transverse processes of atlas Atlanto-axial joint—full flexion

93%

30%

Mobility

59%

63%

 

Pain

68%

54%

Atlanto-axial joint—full lateral flexion

Mobility

64%

59%

Pain

89%

63%

C2

Mobility

76%

38%

Pain

76%

31%

C3

Mobility

62%

52%

Pain

66%

45%

C4

Mobility

63%

50%

Pain

83%

48%

C5

Mobility

63%

40%

Pain

79%

41%

C6

Mobility

77%

19%

Pain

92%

23%

Kappa is calculated for mobility (normal or hypomobile) and pain (pain or no pain).

AROM performed with a gravity goniometer are

reliable and acceptable for clinical use. Reliability refers

to the consistency of a measurement to yield the same

results when the testing procedure is repeated on a

specific population and the construct measured by the

test has not changed (Guyatt et al., 1992; Shrout, 1998). Interpretation of the confidence intervals around the ICC values for cervical AROM leads to the conclusion that, even considering the worst-case scenario (lower boundaries of the 95% CI ¼ .6), the reliability of any cervical AROM measured with a gravity goniometer is still satisfactory for clinical use. Measurement error, determined in this study by calculating the MDC, provides a threshold for inter-

preting the measurements over time. For example, when

the AROM value for extension or flexion changes more than 16 1 , one can be reasonably confident that true change has occurred beyond that which can be attributable to measurement error. Knowledge of the

MDC is essential when investigating the effect of

interventions on change in cervical AROM in patients with neck pain. Our results of reliability of cervical AROM were similar to prior studies that investigated patients with neck dysfunction. Tucci et al. (1986)

reported ICC values from .80 to .91 and Wainner et al. (2003)reported ICC values from .63 to .84 . Our values of measurement error were similar to the results reported by Wainner et al. (2003) (SEM from 4.6 1 to 7.3 1 ). No previous studies have reported the MDC. In addition to the reliability and precision of measurement, understanding the relationship between cervical AROM and measures of disability helps to

establish the validity of AROM measurement and can help clinicians interpret the meaning of this measure- ment (Hains et al., 1998). Therefore, we tested if the measures of AROM were associated with disability scores. Although the associations were only fair, (Portney and Watkins, 1993) explaining no more than 18% (r 2 ¼ .43 2 ) of the variability in disability, the results seem to indicate that physical therapists should pay attention to changes in total saggital and transverse planes of motion when assessing patients with neck pain. Improvement in AROM in these planes will probably be relevant and may reflect in better function. These relationships make empirical sense, since ade- quate range of motion in the saggital and transverse planes are required in most activities of daily living such as desk or computer work, driving, housekeeping, grooming, and eating. The results of this study indicate that Kappa values for symptom reproduction during AROM can be consistently reproduced and assessed for movements in the saggital (flexion and extension) and transverse planes (rotations). However, right rotation in full flexion and left lateral bending has low reliability. Because we cannot explain why left rotation in flexion and right lateral bending had better reliability values than the same movements to the contralateral side, we advise caution regarding interpretation of the consistency of measuring symptom reproduction during rotation in flexion and lateral bending in general. During clinical practice we have noticed more discrepancy in symptom reproduction during repeated lateral bending than during movements in the saggital or transverse planes.

328

ARTICLE IN PRESS

S.R. Piva et al. / Manual Therapy 11 (2006) 321–330

During repeated lateral bending sometimes the patients

for

tenderness when the palpation reproduced the same

report local symptoms whereas at other times the

symptom that the patient was experiencing. Therefore,

symptoms radiate to the arm or show no change at all.

this test may be helpful to identify the source of

Therefore, it may be that the symptoms produced during movements of lateral bending and rotation in flexion truly change when the test is repeated. Our results are comparable to the ones reported by Pool

symptoms. Regarding the atlanto-axial tests of mobility, low reliability was found in all techniques used: rotation during full neck flexion or rotation during full neck lateral flexion. The low reliability cannot be explained

et al. (2004). They recorded pain reproduction using an

by

the prevalence of positive findings, since around 60%

11-point pain scale and calculated reliability using the ICC. The study reported ICC of .71 for provoked pain

of

during atlanto-axial joint test using the technique of

the patients had positive tests. The presence of pain

in

extension, .63 for flexion, .70 for right rotation, .66

rotation with the neck in full lateral flexion had a

for left rotation, .65 for right lateral bending and .45 for

moderate reliability, with a fair lower bound of the 95%

left lateral bending. Rotation in full flexion was not investigated in that study (Pool et al., 2004). We proposed to test AROM of neck rotation in full flexion to grade atlanto-axial rotation. Although the reliability of this measurement was good, we are not

(.5). We believe this moderate reliability is due to the

consistency of pain reproduction during the full passive lateral flexion rather than the rotation component added at the end of the movement. Regarding the reliability of PIM for mobility and pain in the mid and lower neck, we observed that judgments

CI

sure if this test really measures atlanto-axial rotation or atlanto-axial dysfunction. We theorize that in full neck

a

fully opened position, the additional movement in

of

hypomobility were not consistent. Since we used

flexion, because the lower cervical spine segments are in

procedures to minimize the possibility that the PIM by the first examiner would cause a true change in the

rotation would have to come from the upper neck, more likely the atlanto-axial joint (Hertling and Kessler, 1996; Bogduk and Mercer, 2000). We have not observed any

patient’s restriction in motion to the next examiner, we believe that consistency of mobility findings during these tests may not be attainable. Although true change in

association between this test and the traditional PIM to test the atlanto-axial joint in full flexion (Hertling and Kessler, 1996). Because this study was not intended to test diagnostic accuracy, we cannot suggest these tests are specific to the hypothesized spinal segments or

segmental restriction may play a role, it is a factor not easy to control. In addition, the agreement between the testers was relatively low, which supports the low Kappa values. On the other hand, symptom reproduction has shown fair to moderate reliability in the lower segments

dysfunctions.

of

C4–C6. Therefore, it may be that during the PIM

Our results for the PIM of the upper neck indicate that the hypomobility in the occipital-atlanto joint can be consistently reproduced and assessed during lateral glides of the occiput on the atlas (Kappa of .81, agreement of 93%) and during lateral bend of the head with a fixed axis (Kappa of .35, agreement of 90%). This later measure of PIM showed a high percentage of agreement between examiners but low Kappa coeffi- cients. This was probably due to low prevalence of positive findings (10%) (Table 3). The low prevalence of positive findings of the lateral displacement of axis likely resulted in an artificial deflation of the Kappa statistic. The Kappa coefficient is influenced by the prevalence of the attribute (e.g. a disease or clinical sign). If the prevalence is high, chance agreement is also high and kappa is reduced accordingly (Sim and Wright, 2005). To overcome this problem and have a better distribution of positive findings, future studies should investigate upper cervical PIM using only patients with apparent upper neck complaints. In addition, in this study the patient’s pain response may have also influenced the

tests, clinicians should somewhat rely on symptom reproduction of the lower neck when making treatment decisions. While we cannot do direct comparison of the reliability results for PIM between our results and other studies because the techniques used for testing were different, in general, we have found better reliability for PIM than prior studies (Fjellner et al., 1999; Smedmark et al., 2000; Pool et al., 2004). Some may argue that for the mobility classification we only used the categories hypomobility or normal. We did not classify mobility as hypermobility because in everyday practice when we perform PIM of the neck we look predominantly for hypomobility of one segment relative to the other segments. In this study, hypomo- bility was defined as when decreased mobility was noted to one side compared to the opposite side. Therefore, we do not discard the possibility that in some segments which were classified as having normal mobility may have shown some increased mobility. We caution the reader that some of these tests with a somewhat lower reliability coefficient may demonstrate

consistency of measures of mobility during PIM of the

useful validity in future investigations. To date, there is

occipital-atlanto joints.

no

accepted reference standard of cervical dysfunction

Tenderness over the transverse processes of atlas was

with which to validate these tests and measures as useful

reliable. Because the transverse processes of atlas are generally tender, we clarify that we considered positive

diagnostic tools. However, instead of investigating the potential diagnostic accuracy of these tests, future

ARTICLE IN PRESS

S.R. Piva et al. / Manual Therapy 11 (2006) 321–330

329

studies could establish the criterion validity of these tests to guide the selection of interventions and establish prognosis in patients with neck pain.

5. Conclusions

Cervical spine AROM measurement demonstrated moderate to substantial inter-tester reliability and resulted in a MDC adequate for clinical use. The effect of AROM on symptom provocation also resulted in moderate to substantial reliability for tests of symptom reproduction for cervical flexion and rotation. Measures of PIM resulted in substantial and moderate reliability of assessing occipital-atlas mobility, tenderness of the transverse processes of atlas, and symptom provocation during PIM testing of the lower cervical segments. Low prevalence of positive findings likely resulted in an artificial deflation of the Kappa statistic during some PIM measures. Measures of AROM in the saggital and transverse planes were significantly associated with disability scores. Findings are relevant to plan future studies to establish the criterion validity of these tests to guide the selection of interventions and establish prognosis in patients with neck pain. Disclaimers The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the US Air Force or Department of Defense.

References

Bogduk N, Mercer S. Biomechanics of the cervical spine. I: normal kinematics. Clinical Biomechanics 2000;15(9):633–48. Capuano-Pucci D, Rheault W, Aukai J, Bracke M, Day R, Pastrick M. Intratester and intertester reliability of the cervical range of motion device. Archives of Physical Medicine And Rehabilitation

1991;72(5):338–40.

Childs JD, Piva SR, Whitman JM. Lower cervical spine. In: Physical Therapy for the cervical spine and temporomandibular joint. Home study course 13.3, Orthopaedic Section of the American Physical Therapy Association, La Crosse, WI. 2003. Cohen J. A coefficient of agreement for nominal scales. Educational and Psychological Measurement 1960;20:37–46. Cohen J. Statistical power analysis for the behavioral sciences. Hillsdale: Lawrence Erlbaum Associates, Inc.; 1988. Erhard RE. Manual therapy in the cervical Spineorthopedic. Physical therapy home study course. American Physical Therapy Associa- tion, Orthopaedic Section. 1996. Fjellner A, Bexander C, Faleij R, Strender LE. Interexaminer reliability in physical examination of the cervical spine. Journal of Manipulative and Physiological Therapeutics 1999;22(8):511–6. Guyatt GH, Kirshner B, Jaeschke R. Measuring health status: what are the necessary measurement properties? Journal of Clinical Epidemiology 1992;45(12):1341–5. Hains F, Waalen J, Mior S. Psychometric properties of the neck disability index. Journal of Manipulative and Physiological Therapeutics 1998;21(2):75–80.

Hertling D, Kessler RM. Management of common musculoskeletal disorders, 3 ed. Philadelphia: Lippincott; 1996 Chapter 17, p. 540. Hole DE, Cook JM, Bolton JE. Reliability and concurrent validity of two instruments for measuring cervical range of motion: effects of age and gender. Manual Therapy 2000;1(1):36–42. Jordan K. Assessment of published reliability studies for cervical spine range-of-motion measurement tools. Journal of Manipulative and Physiological Therapeutics 2000;23(3):180–95. Kadir N, Grayson MF, Goldberg AAJ, Swain MC. A new neck goniometer. Rheumatology and Rehabilitation 1981;20:219–26. Magee DJ. Orthopedic physical assessment. Philadelphia: Saunders Co; 1997 Chapter 1, p. 9 & Chapter 3, p. 137. Maitland GD. Vertebral manipulation, 5th ed. Sydney, New South Wales, Australia: Butterworths; 1986. Mannion AF, Klein GN, Dvorak J, Lanz C. Range of global motion of the cervical spine: intraindividual reliability and the influence of measurement device. European Spine Journal 2000;9(5):379–85. McKenzie RA. Cervical and thoracic spine: mechanical diagnosis and therapy. Minneapolis: Orthopaedic Physical Therapy Products;

1990.

Nilsson N. Measuring passive cervical motion: a study of reliability. Journal of Manipulative and Physiological Therapeutics 1995;

18:293–7.

O’Driscoll SL, Tomenson J. The cervical spine. Clinics in Rheumatic Diseases 1982;8:617–30. Petersen CM, Johnson RD, Schuit D. Reliability of cervical range of motion using the OSI CA 6000 spine motion analyser on asymptomatic and symptomatic subjects. Manual Therapy 2000;

5(2):82–8.

Pool JJ, Hoving JL, de Vet HC, van Mameren H, Bouter LM. The interexaminer reproducibility of physical examination of the cervical spine. Journal of Manipulative and Physiological Ther- apeutics 2004;27:84–90. Portney LG, Watkins MP. Foundations of clinical research: applica- tions to practice. Stamford: Appleton & Lange; 1993 [Chapter 5, p. 58, and Chapter 26, p. 523–24]. Rheault W, Albright B, Byers C, Franta M, Johnson A, Skowronek M. Intertester reliability of the cervical range of motion device. Journal of Orthopaedic & Sports PhysicalTherapy 1992;15:147–50. Shrout PE. Measurement reliability and agreement in psychiatry. Statistical Methods in Medical Research 1998;7(3):301–17. Shrout PE, Fleiss JL. Intraclass correlations: uses in assessing rater reliability. Psychological Bulletin 1979;86:420–8. Sim J, Wright CC. The kappa statistic in reliability studies: use, Interpretation, and sample size requirements. Physical Therapy

2005;85:257–68.

Simel DL, Samsa GP, Matchar DB. Likelihood ratios with confidence:

sample size estimation for diagnostic test studies. Journal of Clinical Epidemiology 1991;44(8):763–70. Smedmark V, Wallin M, Arvidsson I. Inter-examiner reliability in assessing passive intervertebral motion of the cervical spine. Manual Therapy 2000;5(2):97–101. Solinger AB, Chen J, Lantz CA. Standardized initial head position in cervical range-of-motion assessment: reliability and error analysis. Journal of Manipulative and Physiological Therapeutics 2000;

23(1):20–6.

SPSS for Windows 10.0, 1998. SPSS Inc, Chicago. Stratford PW, Goldsmith CH. Use of standard error as a reliability index of interest: an applied example using elbow flexor strength data. Physical Therapy 1997;77(7):745–50. Stratford PW, Riddle DL, Binkley FM, Spadoni G, Westaway MD, Padfield B. Using the neck disability Index to make decisions concerning individual patients. Physiotherapy Canada 1999;51:107–12. Tucci SM, Hicks JE, Gross EG, Campbell W, Danoff J. Cervical motion assessment: a new, simple and accurate method. Archives of Physical Medicine and Rehabilitation 1986;67:225–30.

330

ARTICLE IN PRESS

S.R. Piva et al. / Manual Therapy 11 (2006) 321–330

Vernon H, Mior S. The neck disability index: a study of reliability and validity. Journal of Manipulative and Physiological Therapeutics

1991;14:409–15.

Viikari-Juntura E. Interexaminer reliability of observations in physical examinations of the neck. Physical Therapy 1987;67:1526–32. Wainner RS, Fritz JM, Irrgang JJ, Boninger ML, Delitto A, Allison S. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine

2003;28(1):52–62.

Werneke M, Hart DL. Centralization phenomenon as a prognostic factor for chronic low back pain and disability. Spine 2001;26(7):758–64. Youdas JW, Carey JR, Garrett TR. Reliability of measurements of cervical spine range of motion—comparison of three methods. Physical Therapy 1991;71(2):98–104.

Further reading

Christensen HW, Nilsson N. The reliability of measuring active and passive cervical range of motion: an observer-blinded and randomized repeated-measures design. Journal of Manipulative and Physiological Therapeutics 1998;21(5):341–7. Jette DU, Jette AM. Physical therapy and health outcomes in patients with spinal impairments. Physical Therapy 1996;76(9):

930–41.

Jordan K, Dziedzic K, Jones PW, Ong BN, Dawes PT. The reli- ability of the three-dimensional FASTRAK measurement system in measuring cervical spine and shoulder range of motion in healthy subjects. Rheumatology (Oxford) 2000;39(4):

382–8.