CLINICAL DECISION MAKING regarding the management

Transcription

1 1388 ORIGINAL ARTICLE Interrater Reliability of the History and Physical Examination in Patients With Mechanical Neck Pain Joshua A. Cleland, DPT, PhD, OCS, John D. Childs, PT, PhD, MBA, OCS, Julie M. Fritz, PT, PhD, ATC, Julie M. Whitman, PT, DSc, OCS ABSTRACT. Cleland JA, Childs JD, Fritz JM, Whitman JM. Interrater reliability of the history and physical examination in patients with mechanical neck pain. Arch Phys Med Rehabil 2006;87: Objective: To examine the interrater reliability of the history and physical examination in patients with mechanical neck pain. Design: Single-group repeated measures for interrater reliability. Setting: Outpatient physical therapy clinic. Participants: Twenty-two patients with mechanical neck pain underwent a standardized history and physical examination by a physical therapist. Intervention: Following a 5-minute break, a second therapist who was blind to the findings of examiner 1 performed the second standardized history and physical examination. Main Outcome Measures: The Cohen and weighted were used to calculate the interrater reliability of ordinal level data from the history and physical examination. Intraclass correlation coefficients model 2,1 (ICC 2,1 ) and the 95% confidence intervals were calculated to determine the interrater reliability for continuous variables. Results: The coefficients ranged from.06 to.90 for the variables obtained from the history. Reliability values for categorical data collected during the physical examination ranged from no to substantial agreement depending on the particular test and measure. ICC 2,1 for cervical range of motion (ROM) measurements ranged between.66 and.78. Conclusions: We have reported the interrater reliability of the history and physical examination in a group of patients with a primary report of neck pain. The reliability variables varied considerably for manual assessment techniques and were significantly higher for the examination of muscle length and cervical ROM. Ultimately, it will be up to each clinician to determine if a particular test or measure poses adequate reliability to assist in the clinical decision making process. Key Words: Medical history taking; Neck; Physical examination; Rehabilitation; Reliability and validity; Spine by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation From the Department of Physical Therapy, Franklin Pierce College, Concord, NH (Cleland); Rehabilitation Services, Concord Hospital, Concord, NH (Cleland); U.S. Army-Baylor University Doctoral Program in Physical Therapy, San Antonio, TX (Childs); Division of Physical Therapy, University of Utah, Salt Lake City, UT (Fritz); Intermountain Health Care, Salt Lake City, UT (Fritz); and Department of Physical Therapy, Regis University, Denver, CO (Whitman). Supported by the Orthopaedic Section of the American Physical Therapy Association. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated. Reprint requests to Joshua A. Cleland, DPT, PhD, OCS, 47 Moore Rd, Hillsboro, NH 03244, clelandj@fpc.edu /06/ $32.00/0 doi: /j.apmr CLINICAL DECISION MAKING regarding the management of patients with neck pain is often based on the findings of the clinical examination as opposed to diagnostic imaging. 1 However, the most common method of classifying patients with neck pain is based on identifying the underlying pathology causing the condition 2 ; despite the complexities of identifying an underlying pathology associated with a patient s neck pain. 3-5 Even if the pathology can be identified, it is often of limited usefulness in selecting the most beneficial interventions. 6,7 The classification of patients is most beneficial to physical therapists when it is based on signs and symptoms identified during the clinical examination and when it is used to categorize subgroups of patients that are homogeneous with respect to the outcomes of particular interventions, instead of pathologic causes. 8 In other words, the goal of classification by physical therapists is to use the examination process to identify groups of patients who are most likely to respond to a particular type of intervention. A recently proposed classification system 9 has identified 5 subgroups of patients with neck pain. Each subgroup is classified through data collected during the patient history and physical examination to identify which particular patients are likely to benefit from a specific treatment strategy. 9 Due to the dependence on the patient history and physical impairment information for clinical decision making in this classification system 9 as well as others for patients with neck pain, 10,11 it is important that measures used to guide decision-making possess an adequate degree of reliability within the context of their intended use A number of studies have reported the reliability of various components of the patient history or physical examination for patients with neck pain Only a few previous studies have reported the findings of the entire physical examination, and none of these included any aspects of the patient history. Some of these studies 20,21 were performed on asymptomatic subjects, which does not allow the results to be generalized to a patient population with neck pain. Other studies have used patients with primarily radicular symptoms. 22,23 Patients with radicular symptoms might respond differently to tests and measures than patients whose primary report is neck pain. Considering the fact that few studies have reported reliability of the complete examination for a population without radicular or neurogenic symptoms, and the fact that obtaining a history can influence the reliability of the physical examination, 22 the purpose of this study was to examine the interrater reliability of both the patient history and physical examination in a cohort of patients with a primary report of neck pain. METHODS Participants We recruited the subjects included in this analysis from patients participating in a prospective cohort study of patients with a primary report of mechanical neck pain referred to physical therapy (PT) at the Rehabilitation Services at Concord

2 RELIABILITY OF THE CERVICAL SPINE EXAMINATION, Cleland 1389 Hospital, Concord, NH. Inclusion criteria for the cohort study included patient age between 18 and 60 years, a Neck Disability Index (NDI) score greater than 10%, and a primary complaint of neck pain with or without referral of symptoms to the upper extremity(ies). Exclusion criteria included any signs or symptoms consistent with a nonmusculoskeletal etiology for the patient s symptoms, a history of a whiplash injury within the past 6 weeks, evidence of central nervous system involvement, 2 or more signs consistent with nerve root compression (myotomal weakness, sensory deficits in a dermatomal pattern, decreased muscle stretch reflexes), prior surgery to the cervical or thoracic spine, or pending legal action regarding their neck pain. A total of 22 subjects agreed to undergo a second examination and signed an informed consent approved by the institutional review board at Concord Hospital. Demographics and baseline descriptors of the patient population can be found in table 1. Examiners Four physical therapists participated as the examiners for the reliability analysis. All therapists underwent a standardized training regimen, which included studying a manual of standard operating procedures with the operational definitions for each examination procedure as well as video clips of the tests and measures used in this study. All participating therapists then underwent a 1-hour training session focusing on proper performance of all examination procedures. Prior to participating in data collection, all therapists passed a competency examination comprising completion of all examination procedures on a patient presenting with a primary report of neck pain. The participating therapists had been practicing for a mean standard deviation (SD) of years (range, 3 23y). One of the therapists was enrolled in fellowship training in manual PT, but the other 3 therapists had not completed any formal post entry-level training in musculoskeletal assessment. Procedures We used a single-group repeated-measures design to investigate the interrater reliability of the patient history and physical examination in a patient population with mechanical neck pain. Data collection took place between April 2004 and August The therapist who was initially referred the patient for the purpose of examination and treatment of the cervical spine served as the first examiner. The first examiner performed the entire history and physical examination components. Following a 5-minute break, the second therapist, who was blind to the findings of examiner 1, performed the second Table 1: Demographics and Baseline Characteristics of Patients (N 22) Variable Values Age Sex, % female (n) 82 (18) Numeric rating scale for pain* NDI Duration of symptoms this episode (d) Symptoms distal to the shoulder, % (n) 77 (17) Mode of onset: traumatic, % (n) 40 (9) Prior history of neck pain, % (n) 27 (6) NOTE. Values are mean standard deviation (SD) unless otherwise indicated. *Reports the average of the worst, best and current scores for the patient s neck pain over a 24-hour period. history and physical examination. Patients were instructed to not divulge any specific information about the first examination to the second examiner. Each examination lasted approximately 30 minutes. Patient History All patients were asked a sequence of specific questions, which included the mode of onset of their symptoms, which was classified as gradual, sudden (with minimal to no perturbation), or traumatic. Patients were then asked if their symptoms were constant or intermittent, if specific activities aggravated their symptoms (eg, Does turning your head right aggravate your symptoms? ), and if the patient had experienced prior episodes of neck pain. Once the patient history was complete, the examiner immediately proceeded to the physical examination. Physical Examination The physical examination included assessment of posture, active cervical and thoracic spine range of motion (ROM), manual muscle testing, muscle length assessment, and spinal mobility. Further explanation of these physical examination tests and measures is as follows: Postural observation. We examined posture with the patient standing as described by Kendall et al 24 ; however, no plumb line was used. From a sagittal view the examiner identified the presence of any of the following postural displacements: forward head, excessive shoulder protraction, excessive or diminished kyphosis of the cervicothoracic junction, and excessive increase or decrease of the kyphosis T3-5 and T6-10. The operational definitions for postural displacements were as follows: the patient was identified as having a forward head if the patient s external auditory meatus was anteriorly deviated (anterior to the lumbar spine) 24 and the shoulders were identified as protracted if the acromion was also noted to be anteriorly deviated (anterior to the lumbar spine). 24 The examiners were then instructed to identify the contour of the spine for the following groups of segments: C7-T2 (cervicothoracic junction), T3-5, and T6-10. Each group was recorded as normal (no deviation), excessive kyphosis, or diminished kyphosis. 25 Excessive kyphosis was defined as an increase in the convexity and a diminished kyphosis was defined as a flattening of the convexity of the thoracic spine (at each segmental group). 25 Cervical ROM. We assessed measurements of cervical flexion, extension, and side bending with a gravity inclinometer and rotation was assessed with a standard dual-armed goniometer. The examiner also recorded the impact of movement on symptoms (no change, increased pain, decreased pain). Specific operational definitions used for each measurement can be found in appendix 1. Thoracic spine rotation. We used active rotation of the thoracic spine to identify symptom provocation. Patients were asked to place their hands on their opposite shoulder and to rotate the trunk as far as they could in each direction. Care was taken to maintain the cervical spine in a neutral position relative to the upper thoracic spine. The examiner then determined the effect of each movement on the patient s symptoms as follows: (1) no effect, (2) increase symptoms, and (3) decrease symptoms. 26 If the patient did not report an increase in symptoms with active thoracic rotation, overpressure was applied and the effect on the patient s symptoms was assessed. Manual muscle testing. We performed strength testing of the following muscles according to the descriptions provided by Kendall 24 : the middle and lower trapezius, rhomboids, and serratus anterior. Grading of the strength was dichotomized as

3 1390 RELIABILITY OF THE CERVICAL SPINE EXAMINATION, Cleland either within normative limits or reduced as compared with the contralateral side. 27 Muscle length assessment. We performed muscle length assessment of the following muscles according to the guidelines described by Childs et al 26 : latissimus dorsi, pectoralis major and minor, levator scapulae, upper trapezius, anterior and middle scalenes, and the suboccipitals. The physical therapists recorded each muscle assessed as having normal or restricted length. Chin Tuck Neck Flexion Test. The Chin Tuck Neck Flexion Test is an assessment technique intended to determine the endurance of the deep neck flexors 28 : while in supine the patients were asked to tuck their chin in while slightly flexing the neck and lifting the head approximately 2.54cm (1in) off the plinth. This position has been shown to maximally activate the deep neck flexor muscles. 29 The length of time the patient was able to hold this position without deviations was recorded in seconds by the examiner. Spinal mobility testing. We assessed spinal mobility by a variety of methods previously reported in the literature The following techniques are described according to the specific segments that have traditionally been used to assess mobility; however, we acknowledge that these techniques are likely not segment specific. 33,34 Mobility of the occipito-atlantal joint was performed as described by Flynn et al. 30 The patient was supine and the examiner cradled the occiput with both hands. The head was then rotated 30 toward the side to be tested and an anterior to posterior glide was performed to assess the amount of available motion compared with the contralateral side. 30 Mobility of the atlanto-axial joints were also performed with the patient in supine, as described by Greenman. 31 The examiner passively and maximally flexed the neck followed by passive cervical rotation to 1 side and then to the other. The amount of motion to each side was compared, and if 1 side was determined to have less motion it was considered to be hypomobile. 30 Posterior to anterior spring testing of middle to lower cervical spine (C2-7) and upper to middle thoracic spine (T1-9) was performed with the patient prone and the neck in neutral rotation as described by Maitland et al. 32 Spring testing was performed centrally over the spinous processes of the vertebrae and was used to assess both segmental mobility and pain provocation. With the elbows extended, the examiner applied a gentle but firm, anteriorly directed pressure on the spinous process (ie, posterior-anterior). The mobility at each segment was judged as normal, hypomobile, or hypermobile. 35 Interpretation of whether a segment was hypomobile or hypermobile was based on the examiner s perception of the mobility at each spinal segment relative to those above and below the tested segment, and based on the examiner s experience and perception of normal mobility. In addition pain provocation at each segment was judged as painful or not painful. 32 Data Analysis We calculated descriptive statistics, including frequency counts for categorical data and calculation of the mean and SD for continuous variables. The Cohen 36 was used to calculate the interrater reliability of categorical data with only 2 possible response options from the history and clinical examination. The Cohen identifies the percentage agreement between raters that would occur beyond chance. 13 A weighted 37 was used to calculate the reliability of categorical data with 3 response options such as intersegmental mobility assessment techniques as well as the symptom response (no change, centralization, peripheralization). The weighted was calculated with the linear weighting method. 38 Intraclass correlation coefficients (ICC) model 2,1, and the 95% confidence intervals (CIs) were calculated to determine the interrater reliability for continuous variables. 39 In addition, the standard error (SE) of measurement was calculated as SD (1 r), where SD is the standard deviation of the observed scores and r is the reliability coefficient for the particular measurement. 13 The SE of measurement represents the SD of measurement error. 40 The minimal detectable change (MDC) for each continuous variable was calculated using the formula: 1.96 SE of measurement The 95% limits of agreement, indicating the total measure of error was calculated for continuous data with the following formula: mean difference between raters (rater A rater B) 1.96 SD. 41 The limits of agreement represent the values within which 95% of the measurements between raters would lie. 41 Assessment of the reliability for categorical variables was performed using the criteria described by Landis and Koch 14 ; values less than.10 indicated virtually no agreement;.11 to.40 indicate slight agreement;.41 to.60 indicate fair agreement; values between.61 and.80 indicate moderate agreement; and values greater than.81 indicate substantial agreement. Assessment of reliability for continuous variables was performed using criteria described by Shrout 42 with values less than.10 indicating no agreement; values between.11 and.40 indicating slight agreement; values between.61 and.80 indicating moderate agreement; and values greater than.81 indicating substantial agreement. RESULTS Subject characteristics are shown in table 1. The reliability coefficients and corresponding 95% CIs, percentage agreement, and prevalence for the history components of the examination can be found in table 2. The coefficients ranged from.04 to 1.0 for the historical variables. Seven of the 9 variables exhibited moderate to substantial reliability and 2 variables were less than 0, indicating agreement less than chance. However, the 2 variables whose coefficients were less than 0 Turning right aggravates my symptoms and Driving Table 2: Reliability Coefficients for Categorical Variables Obtained in the Historical Examination Variable Prevalence Mode of onset.72 (.47 to.96) 82 45% gradual; 18% sudden; 36% traumatic Nature of neck symptoms.81 (.56 to 1.0) 91 59% constant; 40% intermittent Prior episode of neck pain.90 (0.7 to 1.0) 96 68% no; 32% yes Turning right aggravates symptoms.04 (.11 to.02) 91 95% worse; 5% no change Turning left aggravates symptoms 1.0 (1.0 to 1.0) % worse; 36% no change Looking down aggravates symptoms.79 (.51 to 1.0) 91 86% worse; 14% no change Looking up aggravates symptoms.80 (.55 to 1.0) 91 32% worse; 68% no change Driving aggravates symptoms.06 (.39 to.26) 86 95% worse; 5% no change Sleeping aggravates symptoms.90 (.72 to 1.0) 95 59% worse; 41% no change

4 RELIABILITY OF THE CERVICAL SPINE EXAMINATION, Cleland 1391 Table 3: Descriptive Statistics, Reliability Information, and Measurement Accuracy for Active Cervical ROM and Deep Neck Flexor Endurance Assessment Motion Mean SD ICC 2,1 SEM (deg) MDC (deg) LOA (deg) Cervical flexion* (.50.89) Cervical extension* (.48.88) Cervical side-bending right* (.33.84) Cervical side-bending left* (.40.86) Cervical rotation right (.55.90) Cervical rotation left (.52.90) Chin Tuck Neck Flexion Test (s) (.14.81) Abbreviations: LOA, limits of agreement; SEM, standard error of measurement. *Measurement with a gravity inclinometer. Measurement with a standard dual-armed goniometer. aggravates my symptoms might have been artificially deflated by high prevalence levels (95% positive findings for both). 13 The reliability coefficients with 95% CIs, means, SDs, and the SE of measurement for the continuous variables collected during the physical examination can be found in table 3. All measurement of cervical ROM exhibited an ICC value indicating moderate to substantial reliability. The measurement of deep neck flexor endurance exhibited slight agreement between raters. The SE of measurement for ROM ranged between 3.6 and 7. The MDC for cervical range of motion measurements ranged from 10 to 19. The limits of agreement can be found in table 3. The SE of measurement for the deep flexor muscle endurance was 2.3 seconds. The reliability of symptom response as calculated with the weighted during active ROM varied considerably for both the reproduction of pain ( range, ) and for the determination of centralization or peripheralization ( 0.06 to 1.00) (table 4). The weighted calculations for symptom response during thoracic rotation ranged from.03 (95% CI,.11 to.04) for right rotation and.70 (95% CI, ) for left rotation (table 5). Reliability coefficients for strength assessment ranged from.04 to.77 with the overall agreement ranging from 41% to 91%. The prevalence for positive findings for the strength assessment for those reliability coefficients below 0 was 95% for positive findings for the middle trapezius on the right and both lower trapezius muscles (table 6). The calculated for the assessment of muscle length ranged from moderate to almost perfect (table 7). The reliability of postural assessment exhibited a value between moderate and substantial with the exception of a forward head posture, which exhibited a value of 0.1 and a prevalence of 90% (see table 5). The results for assessment of mobility testing and symptom response of the cervical spine are reported in table 8 and for the thoracic spine in table 9. The weighted values for cervical spine mobility ranged from.26 to.74 and for provocation of pain during mobility assessment between.52 and.90. values for thoracic spine mobility exceeded those of the cervical spine and ranged from slight to moderate while pain provocation during mobility testing in the thoracic spine ranged from.11 to.90. DISCUSSION Clinicians should understand the reliability of the findings obtained during the clinical examination when using these measures to make decisions about individual patients regarding the diagnosis, prognosis, or the identification of appropriate treatment strategies. We have reported the interrater reliability data for a standardized clinical examination performed on a group of patients presenting to PT with a primary report of neck pain. We will discuss the findings of our study relative to the qualitative assessment of reliability previously described by Landis and Koch 14 for values and Shrout 42 for ICCs. We were only able to identify 1 article 27 that investigated the reliability of components of both the history and physical examination. Wainner 12 investigated the reliability of several questions in a group of patients presenting to an electrophysiologic laboratory with a suspected diagnosis of cervical radiculopathy or carpal tunnel syndrome. Their values ranged from.53 to.82, which was similar to our findings with the exception of 2 questions, which exhibited poor reliability but excellent agreement (86% and 91%, respectively). It has been reported 43 that the history component of an examination might be the most useful in guiding decision making in both the PT and primary care setting. Our findings and those of Wainner 12 suggest that components of the historical examination can be reproduced with substantial agreement. Cervical ROM measurements are not only used in the classification of patients with neck pain into subgroups, 9-11 but have also been shown to be beneficial prognostically to identify patients who are likely to improve between sessions. 44 The Table 4: Kappa Values,, and Prevalence for Assessing Symptom Response During Active ROM Pain Reproduction With Cervical ROM Centralization/Peripheralization With Cervical ROM Motion Assessed Positive Findings (%) Centralization (%) Peripheralization (%) Flexion.55 (.23 to.87) (1.0 to 1.0) Extension.23 (.09 to.37) (.17 to.71) Side-bend right.81 (.57 to 1.0) (.15 to.03) Side-bend left 0.0 (.22 to.23) (.25 to.66) Rotation right.40 (.07 to.87) (.15 to.03) Rotation left.73 (.46 to 1.0) (.21 to.00)

5 1392 RELIABILITY OF THE CERVICAL SPINE EXAMINATION, Cleland Table 5: Reliability Coefficients for Postural and Qualitative Thoracic ROM Assessment Variable Prevalence Forward head 0.1 ( 0.2 to.00) Excessive shoulder protraction.83 (.51 to 1.0) C7-T2 excessive kyphosis.79 (.51 to 1.0) T3-5 excessive kyphosis.69 (0.3 to 1.0) T3-5 decreased kyphosis.58 (.22 to.95) T6-10 excessive kyphosis 0.9 (.74 to 1.0) T6-10 decreased kyphosis 0.9 (.73 to 1.0) Thoracic rotation right.03 (.11 to.04) Thoracic rotation left 0.7 (0.4 to 1.0) reliability coefficients for the cervical ROM measurements in this study are moderate to substantial, and even the lower boundary estimates of the 95% CI exhibited at least slight agreement. This coincides with reliability measures of other studies reported in the literature. 19,27,45 In addition, the standard error of measure for the cervical ROM measurements in our study is comparable to those identified by Piva et al. 19 Considering these findings cervical ROM measurements as described in this study are appropriate for guiding clinical decision making. However, to be certain that a true change in cervical ROM has occurred, the measurements must exceed the MDC, which ranged from 10 to 19. Our study is the first to report the reliability associated with identifying the presence of centralization or peripheralization during active cervical ROM. The findings suggest that the interrater reliability of assessing centralization of symptoms during cervical flexion and extension is fair to substantial; however, there existed no to poor reliability for side bending as well as rotation. Considering the relatively small 95% CI it appears that the centralization and peripheralization during active ROM assessment is only reliable for sagittal plane movements. Despite the use of a standardized protocol for assessing cervical mobility, the overall findings for reliability of mobility assessment and pain provocation were highly variable. The inconsistent reliability coefficients in our study are similar to the findings in the cervical spine reported by other researchers. 15,21 Additionally, Smedmark et al 16 found fair to moderate reliability in the identification of stiffness in the cervical spine. The higher agreement in the Smedmark 16 study could have potentially been related to the experience of the clinicians or the fact that the researchers dichotomized the findings as stiffness or no stiffness. Van Suijlekom et al 46 demonstrated slight to fair agreement of the identification of pain with joint pressure pain; however, they classified the cervical spine as Table 6: Reliability Coefficients for Muscle Strength Assessment Muscle Assessed Prevalence of Muscle Tightness (%) Middle trapezius right.07 (.56 to.42) Middle trapezius left * * 100 Lower trapezius right.04 (.11 to.02) Lower trapezius left.04 (.11 to.02) Rhomboid right.72 (.44 to 1.0) Rhomboid left.71 (.41 to 1.0) Serratus right.11 (.56. to.78) Serratus left.77 (.48 to 1.0) *Unable to calculate due to 100% prevalence. high, middle, or lower and the clinician did not identify a specific segment, which could potentially have increased the reliability of their findings. In agreement with Hicks et al 47 who found high variability in the assessment of lumbar spine mobility, we believe this variability may occur due to clinicians not accurately identifying the specific cervical segment tested rather than to the process of determining mobility and pain provocation. Interexaminer identification of specific lumbar segments has been shown to exhibit poor reliability 48 and we would expect the reliability of identifying a specific segment in the cervical spine would exhibit comparable values. We believe that this may also contribute to the variability of reliability that occasionally occurred between segments. Additionally the 95% CIs are rather large suggesting that the reliability of mobility assessment of the cervical spine requires further investigation prior to being used to guide clinical decision making. The values for mobility assessment in the thoracic spine were much higher than that of the cervical spine. With the exception of posterior to anterior mobility of T7 (.13), the remainder of the correlation coefficients exhibited at least fair agreement. However, the 95% CIs were rather large for some of the variables, spanning from poor to excellent reliability. This wide CI suggests that uncertainty continues to exist regarding the reliability of mobility testing in some areas of the thoracic spine. The weighted values for thoracic mobility testing are dramatically higher than others reported in the literature. 49,50 Perhaps this is related to the fact that Haas et al 49 Table 7: Reliability Coefficients for Muscle Length Assessment Muscle Prevalence of Positive Findings (%) Latissimus dorsi right.80 (.53 to 1.0) Latissimus dorsi left.69 (.30 to 1.0) Pectoralis minor right.81 (.57 to 1.0) Pectoralis minor left.71 (.43 to 1.0) Pectoralis major right.90 (.72 to 1.0) Pectoralis major left.50 (.01 to 1.0) Levator scapulae right.61 (.26 to.95) Levator scapulae left.54 (.19 to.90) Upper trapezius right.79 (.52 to 1.0) Upper trapezius left.63 (.31 to.96) Anterior and middle scalenes right.81 (.57 to 1.0) Anterior and middle scalenes left.62 (.29 to.96) Suboccipitals right.63 (.26 to 1.0) Suboccipitals left.58 (.15 to 1.0) 86 18

6 RELIABILITY OF THE CERVICAL SPINE EXAMINATION, Cleland 1393 Table 8: Reliability Coefficients for Assessment of Mobility and Pain Provocation in the Cervical Spine Mobility Assessment Pain Provocation Motion Segment Assessed Prevalence Hypomobility (%) Hypermobility (%) Pain Provocation (%) Segmental mobility C0-1 right.26 (.57 to.07) ( 0.9 to.14) Segmental mobility C0-1 left.46 (.05 to.86) (.37 to.54) Segmental mobility C1-2 right rotation.72 (.43 to.21) (.05 to.36) Segmental mobility C1-2 left rotation.74 (0.4 to 1.0) (.56 to.22) PA mobility at C2.01 (.35 to.38) (.04 to.31) PA mobility at C3.10 (.25 to.44) (.21 to.47) PA mobility at C4.10 (.22 to 0.4) (.12 to.67) PA mobility at C5.10 (.15 to.35) (.09 to.42) PA mobility at C6.01 (.21 to.24) (.22 to.88) PA mobility at C7.54 (0.2 to.88) (.72 to 1.0) Abbreviation: PA, central posterior to anterior spring testing. examined the mobility of the thoracic spine in a group of students of whom only 50% reportedly experienced either pain or stiffness, whereas we performed the examination on patients referred to PT with a primary report of neck pain. The 2 examinations in the Christensen et al 50 study occurred 24 hours from each other while in our study the examination was performed within 1 hour of each other. It is plausible that a patient s status could change over a 24-hour period resulting in greater variations in values as found in the Christensen 50 study. The reliability of postural assessment, with the exception of assessment of forward head posture, revealed acceptable values, with the 95% CI ranging from slight to substantial. These values are similar to those reported by Griegel-Morris et al. 25 These researchers examined the reliability of judgments of postural deviations from a plumb line on a 0 to 5 scale and reported a high degree of reliability ( range,.61.83). 25 However, individual postural deviations were not assessed by Griegel-Morris, 25 making direct comparison to our findings impossible. Similar to our findings, Eriksson et al 51 examined the reliability of identifying specific postural deviations in the cervical and thoracic spine from a lateral view with the use of a postural grid which ranged from.48 to.79, indicating that assessment of posture has reasonable reliability. Only 2 other studies 20,21 have investigated the reliability of muscle length assessment of the upper quarter. Fjellner et al 21 did not calculate the values for their agreement for the assessment of the levator scapulae muscle and trapezius muscle length. They reported that the prevalence of findings was high (range, 89% 96%), and this high prevalence would have artificially deflated the values. Strender et al 20 determined that length assessment of the upper trapezius muscle was poor (.075), which was considerably lower than our findings, which ranged from.58 to.90. The reliability coefficients for assessing the length of muscles of the upper quarter in our study ranged from fair to substantial, with the majority of the 95% CIs falling within the fair to substantial range. These values suggest that these tests may be useful in categorizing patients with neck pain into subgroups in which they receive specific interventions focusing on these specific impairments. 26 Additionally, our findings for the reliability of muscle strength assessment range from no to moderate agreement. We expect the low scores may have been artificially lowered as a result of the high prevalence rates of identified weakness of the lower trapezius muscles. Kappa coefficient values for upper-extremity manual muscle testing when the examiner rates the strength as either normal or reduced have been reported to be between.25 and Reporting the reliability of the entire clinical examination may be considered an advantage of this analysis. However, it is possible that completing an entire examination could have resulted in an increase in tissue irritability, which might have altered the findings of the second exam. Also, even though the examinations were performed with only a 5-minute break period, it is possible the patient s status did not remain stable throughout both examinations. The first examination may have resulted in an increase in irritability of the patient s conditions leading to more positive findings on the second examination. This may be recognized in the limits of agreement values, as the mean scores for 4 of the 6 cervical ROM measurements were lower for the second rater. Perhaps this was a result of increased tissue irritability following the second examination, leading to decreased performance on the part of the patient. It is also likely that having only a 5-minute break between ex- Table 9: Reliability Coefficients for Assessment of Mobility and Pain Provocation With Central Posterior to Anterior Spring Testing in the Thoracic Spine Mobility Assessment Pain Provocation Motion Segment Assessed Hypomobility (%) Hypermobility (%) Pain Provocation (%) T1.67 (.33 to 1.0) (.43 to 1.0) T2.68 (.36 to.99) (.23 to.85) T3.49 (.05 to.98) ( 0.5 to.29) T4.72 (.43 to 1.0) (.73 to 1.0) T5.49 (.19. to.79) (.00 to.45) T6.82 (.59. to 1.0) (.05 to.55) T7.13 (.26 to.53) (.02 to.71) T8.39 (.07 to.87) (.14 to.62) T9.52 (.16. to.89) (.51 to.31) 45 55

7 1394 RELIABILITY OF THE CERVICAL SPINE EXAMINATION, Cleland aminations could have inflated the values for the historical examination; however, this short interval between examinations was selected to allow the study to be completed in 1 session. 53 It is also possible that prevalence bias artificially affected some of the values, because the prevalence for a number of tests was below 10% or greater than 90% and often when this is the case values are not calculated. 36 In addition, the small sample size resulted in a number of occurrences of high prevalence rates, which could alter the ratings. Additionally, it is possible that the sample size might have contributed to wide CIs in some areas. CONCLUSIONS We have reported the interrater reliability of the history and physical examination in a group of patients with a primary report of neck pain. The results of our study suggest that the cervical ROM measurements, centralization, and peripheralization during active ROM of flexion and extension, postural assessment, muscle length assessment of the upper quadrant, and strength assessment of the rhomboids exhibit acceptable reliability based on both the point estimates and the 95% CIs. These measures should be considered when classifying patients with neck pain into subgroups. A number of measurements indicated no to poor reliability: centralization and peripheralization with cervical ROM in the transverse and frontal planes, and strength testing of the lower trapezius muscles. The narrow CIs associated with these findings suggest that these measurements are not reliable and that their use in clinical practice should be questioned. We have identified other tests and measures that have exhibited poor to fair substantial reliability including mobility assessment of the cervical and thoracic spine and strength of the serratus anterior muscle. However, the 95% CIs were wide; therefore uncertainty continues to exist regarding the reliability of these measurements. Presenting the reliability coefficients from our study will provide clinicians with reliability data that may assist with selecting appropriate tests or measures when making a decision regarding an individual patient s diagnosis, prognosis, or appropriate treatment interventions. Future studies should investigate the usefulness of the various items in the examination for subgrouping patients with neck pain into treatment-based classifications. Acknowledgments: The funding agency had no role in the study design, writing the manuscript, or in the decision to submit for publication. We thank Madeleine Hellman, EdD, MHM, PT, and Eric Shamus, PhD, MS, PT, for their dissertation committee work at Nova Southeastern University. We also thank Sarah Eberhart, MPT, Sheryl Cheney, PT, and Diane Olimpio, PT, Director of Physical Therapy, Rehabilitation Services of Concord Hospital, Concord, NH, for their assistance with data collection. APPENDIX 1: PROCEDURES USED FOR CERVICAL ROM MEASUREMENTS 26 Starting Position Neck Flexion and Extension Neck Side-Bending Neck Rotation Symptom Response Before taking any measurements all patients were instructed to sit upright and to keep their eyes focused straight ahead. Prior to movement testing, patients reported their current level of symptoms on a numeric pain rating scale and were instructed that these symptoms served as a baseline. For neck flexion, the inclinometer is placed on the top of the patient s head aligned with the external auditory meatus and then zeroed. The patient is asked to flex the head forward as far as possible, bringing the chin to the chest. The amount of neck flexion is recorded from the inclinometer. For extension ROM, the inclinometer is positioned in the same manner, and the patient is asked to extend the neck backwards as far as possible. The amount of neck extension is recorded with the inclinometer. The inclinometer was positioned in the frontal plane on the apex of the patient s head in alignment with the external auditory meatus. To measure right side-bending, the patient was asked to move the right ear to the right shoulder. The amount of side-bending was recorded with the inclinometer. The opposite is performed to measure left side-bending. Care was taken to avoid concomitant rotation or flexion with the side-bending movement. Rotation was measured with a universal goniometer. The patient was seated, looking directly forward with the neck in a neutral position. 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