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Study: inter-tester reliability of passive intervertebral and active movements of the cervical spine. Thirty subjects (age 41712) with neck pain participated in this study. Effect of AROM on patient's symptoms was recorded as no change, decreased, increased, centralization, or peripheralization.
Study: inter-tester reliability of passive intervertebral and active movements of the cervical spine. Thirty subjects (age 41712) with neck pain participated in this study. Effect of AROM on patient's symptoms was recorded as no change, decreased, increased, centralization, or peripheralization.
Study: inter-tester reliability of passive intervertebral and active movements of the cervical spine. Thirty subjects (age 41712) with neck pain participated in this study. Effect of AROM on patient's symptoms was recorded as no change, decreased, increased, centralization, or peripheralization.
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 Systems 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 41712) 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 patients 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 occipitalatlas 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 ndings likely resulted in an articial deation of the Kappa statistic during some PIM measures. Measures of AROM in saggital and transverse planes were associated with disability scores (r :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 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 patients complaint.(Magee, 1997) Measurements of AROM are performed to determine limitations in motion, patients 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 patients complaints in ARTICLE IN PRESS www.elsevier.com/locate/math 1356-689X/$ - see front matter r 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2005.09.001
Corresponding author. Tel.: +1 412 383 6712;
fax: +1 412 383 6629. E-mail address: srpst24@pitt.edu (S.R. Piva). each direction of movement. (Magee, 1997) The effect of each movement on the patients 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 patients symptoms during exion provides some indication that exercises in a exed position may be benecial. 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; ODriscoll 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 patients 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 patients 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, denitions of the assessment techniques were not clear. They only described that movements between the occiput and atlas used a exion technique, assess- ment of atlas/axis mobility used a rotation technique, and segments from C2 to T2 included xation of the lower segmental level and lateral exion 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 exion, C7 exion/extension, and movement of the rst 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 Systems 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 patients symptoms. Patients were excluded if the neck pain was associated with inammatory 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) 321330 322 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-specic 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, exion, rotation in full exion, 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, exion, rotation in full exion, 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 patients 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 patients head during extension and exion. 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 exion was used to grade the atlantoaxial rotation. Patients were in full neck exion and the gravity goniometer was positioned on the back of patients 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 patients 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). ARTICLE IN PRESS Fig. 1. Measurement of active neck extension. Fig. 2. Measurement of active neck exion. S.R. Piva et al. / Manual Therapy 11 (2006) 321330 323 2.3.2. Effect of movement on symptoms The effect of AROM on participants symptoms was recorded such as: no effect, increases symptoms, decreases symptoms, centralizes symptoms, or periph- 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 patients 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 jointlateral glide: The examiner held the patients 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 jointlateral 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 ARTICLE IN PRESS Fig. 3. Measurement of active neck rotation in full exion. Fig. 4. Measurement of active neck rotation in supine. S.R. Piva et al. / Manual Therapy 11 (2006) 321330 324 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 jointfull exion: The examiner sup- ported patients head with both hands and passively moved the patients neck into maximal exion. While maintaining this position, the patients head was rotated rst 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 jointfull lateral bending: The examiner passively moved the patients neck into end range of right lateral-bending. While maintaining this position, the patients 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 patients 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 examiners 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 rst examiner would cause a true change in the patients 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 rst for subject 1; examiner 2 performed the exam rst 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 denitions 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 coefcients on a dichotomous variable (i.e. hypomobile or normal). To ensure sufcient statistical power to achieve a lower bound of the 95% condence 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. Cohens Kappa statistic and the associated 95% condence intervals were used to calculate inter-tester reliability of the classica- tion of mobility and presence of pain during the PIM, and the effect of AROM on the patients symptoms (Cohen, 1960; Simel et al., 1991). The agreement of the effect of AROM on the patients symptoms was based on both examiners placing the patient in the same category of the ve possible ones (e.g. both say increases symptoms; or both say centralizes symptoms). Intra-class correlation coefcient (ICC), formula 2,1, and its 95% condence 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; 0.110.40 indicate slight agree- ment; 0.410.60 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 sdO1r, where r is the testretest reliability coefcient and sd is the standard deviation of the combined scores of both examiners (Stratford and Goldsmith, 1997). The MDC was calculated as 1.96 O2 SEM (Portney and Watkins, 1993). In this formula 1.96 is the standard normal score associated with a two-tailed 95% condence interval and the O2 is included to reect the fact that there is measurement error associated with both the rst and second repeated measures when calculating testretest reliability. The Pearson correlation coefcient was calculated to determine the association between the NDI scores and AROM. ARTICLE IN PRESS S.R. Piva et al. / Manual Therapy 11 (2006) 321330 325 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 91 to 161. Kappa values for symptom reproduction during AROM are also depicted in Table 2. Kappa values of right rotation in exion and left lateral bending were only slight. Symptom reproduction during exion 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 ndings 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 atlantoaxial joint in full lateral exion (.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 (exion+extension) (r :43) and total transverse plane AROM (left rotation+right rotation) (r :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 ARTICLE IN PRESS Table 1 Summary statistics of participants Number 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). 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 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) 5.6 16 .65 (.54: .76) 83% Flexion 60 (13) .78 (.59: .89) 5.8 16 .87 (.81: .94) 93% L e rotation in exion 39 (10) .89 (.78: .95) 3.2 9 .69 (.59: .78) 83% R f rotation in exion 39 (13) .78 (.60: .89) 5.3 15 .25 (.12: .39) 63% L lateral bending 39 (11) .85 (.70: .92) 4.2 12 .28 (.15: .41) 63% R lateral bending 41 (11) .87 (.75: .94) 3.7 10 .75 (.66: .84) 87% L rotation 68 (13) .91 (.82: .96) 4.1 11 .74 (.64: .84) 87% R rotation 68 (14) .86 (.74: .93) 4.8 13 .76 (.67: .84) 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 coefcient. c Standard error of measurement. d Minimum detectable change. e Left. f Right. S.R. Piva et al. / Manual Therapy 11 (2006) 321330 326 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 specic population and the construct measured by the test has not changed (Guyatt et al., 1992; Shrout, 1998). Interpretation of the condence 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 .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 exion changes more than 161, one can be reasonably condent 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 4.61 to 7.31). 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 .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 reect 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 (exion and extension) and transverse planes (rotations). However, right rotation in full exion and left lateral bending has low reliability. Because we cannot explain why left rotation in exion 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 exion 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. ARTICLE IN PRESS 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 jointlateral glide Mobility .81 (.72: .91) 93% 27% Pain .32 (.15:. 49) 77% 27% Occipital-atlanto jointlateral displacement of axis Mobility .35 (.08: .62) 90% 10% Pain .35 (.15: .55) 83% 17% Tenderness over transverse processes of atlas .83 (.74: .92) 93% 30% Atlanto-axial jointfull exion Mobility .21 (.08: .34) 59% 63% Pain .36 (.24: .49) 68% 54% Atlanto-axial jointfull lateral exion Mobility .30 (.17: .43) 64% 59% Pain .61 (.5: .72) 89% 63% C2 Mobility .46 (.33: .59) 76% 38% Pain .42 (.28: .56) 76% 31% C3 Mobility .25 (.12: .38) 62% 52% Pain .29 (.16: .43) 66% 45% C4 Mobility .27 (.13: .40) 63% 50% Pain .65 (.54: .76) 83% 48% C5 Mobility .18 (.03: .33) 63% 40% Pain .55 (.43: .67) 79% 41% C6 Mobility .07 (.34: .20) 77% 19% Pain .76 (.64: .87) 92% 23% Kappa is calculated for mobility (normal or hypomobile) and pain (pain or no pain). S.R. Piva et al. / Manual Therapy 11 (2006) 321330 327 During repeated lateral bending sometimes the patients report local symptoms whereas at other times the symptoms radiate to the arm or show no change at all. Therefore, it may be that the symptoms produced during movements of lateral bending and rotation in exion truly change when the test is repeated. Our results are comparable to the ones reported by Pool et al. (2004). They recorded pain reproduction using an 11-point pain scale and calculated reliability using the ICC. The study reported ICC of .71 for provoked pain in extension, .63 for exion, .70 for right rotation, .66 for left rotation, .65 for right lateral bending and .45 for left lateral bending. Rotation in full exion was not investigated in that study (Pool et al., 2004). We proposed to test AROM of neck rotation in full exion to grade atlanto-axial rotation. Although the reliability of this measurement was good, we are not sure if this test really measures atlanto-axial rotation or atlanto-axial dysfunction. We theorize that in full neck exion, because the lower cervical spine segments are in a fully opened position, the additional movement in 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 association between this test and the traditional PIM to test the atlanto-axial joint in full exion (Hertling and Kessler, 1996). Because this study was not intended to test diagnostic accuracy, we cannot suggest these tests are specic to the hypothesized spinal segments or dysfunctions. 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 xed axis (Kappa of .35, agreement of 90%). This later measure of PIM showed a high percentage of agreement between examiners but low Kappa coef- cients. This was probably due to low prevalence of positive ndings (10%) (Table 3). The low prevalence of positive ndings of the lateral displacement of axis likely resulted in an articial deation of the Kappa statistic. The Kappa coefcient is inuenced 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 ndings, future studies should investigate upper cervical PIM using only patients with apparent upper neck complaints. In addition, in this study the patients pain response may have also inuenced the consistency of measures of mobility during PIM of the occipital-atlanto joints. Tenderness over the transverse processes of atlas was reliable. Because the transverse processes of atlas are generally tender, we clarify that we considered positive for tenderness when the palpation reproduced the same symptom that the patient was experiencing. Therefore, this test may be helpful to identify the source of symptoms. Regarding the atlanto-axial tests of mobility, low reliability was found in all techniques used: rotation during full neck exion or rotation during full neck lateral exion. The low reliability cannot be explained by the prevalence of positive ndings, since around 60% of the patients had positive tests. The presence of pain during atlanto-axial joint test using the technique of rotation with the neck in full lateral exion had a moderate reliability, with a fair lower bound of the 95% CI (.5). We believe this moderate reliability is due to the consistency of pain reproduction during the full passive lateral exion 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 of hypomobility were not consistent. Since we used procedures to minimize the possibility that the PIM by the rst examiner would cause a true change in the patients restriction in motion to the next examiner, we believe that consistency of mobility ndings during these tests may not be attainable. Although true change in 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 of C4C6. Therefore, it may be that during the PIM 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 classication 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 dened 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 classied as having normal mobility may have shown some increased mobility. We caution the reader that some of these tests with a somewhat lower reliability coefcient may demonstrate useful validity in future investigations. To date, there is no accepted reference standard of cervical dysfunction with which to validate these tests and measures as useful 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) 321330 328 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 exion 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 ndings likely resulted in an articial deation of the Kappa statistic during some PIM measures. Measures of AROM in the saggital and transverse planes were signicantly 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. 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