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Manual Therapy 11 (2006) 321330

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 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
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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.
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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.
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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
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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.
Disclaimers
The opinions or assertions contained herein are the
private views of the authors and are not to be construed
as ofcial or as reecting the views of the US Air Force
or Department of Defense.
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