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Inter-and intra-tester reliability of a battery of cervical movement control dysfunctiontests
V. Segarra, L. Dueñas, R. Torres, D. Falla, G. Jull, E. Lluch
PII: S1356-689X(15)00009-0
DOI: 10.1016/j.math.2015.01.007
Reference: YMATH 1670
To appear in: Manual Therapy
Received Date: 7 August 2014
Revised Date: 9 January 2015
Accepted Date: 15 January 2015
Please cite this article as: Segarra V, Dueñas L, Torres R, Falla D, Jull G, Lluch E, Inter-and intra-tester reliability of a battery of cervical movement control dysfunction tests, Manual Therapy (2015), doi:10.1016/j.math.2015.01.007.
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Inter-and intra-tester reliability of a battery of cervical movement control
dysfunction tests
Segarra V1,2
; Dueñas L3; Torres R
3; Falla D
4,5; Jull G
6; Lluch E
3,7
1
CEREDE Sports Medicine, Barcelona, Spain
2 International Institute of Exercise Science and Health
3 Department of Physiotherapy, University of Valencia, Valencia, Spain
4 Pain Clinic, Center for Anesthesiology, Emergency and Intensive Care Medicine, University
Hospital Göttingen, Göttingen, Germany
5 Department of Neurorehabilitation Engineering, Bernstein Focus Neurotechnology
Göttingen, Bernstein Center for Computational Neuroscience, University Medical Center
Göttingen, Georg-August University, Göttingen, Germany
6 Division of Physiotherapy, School of Health and Rehabilitation Sciences, The University of
Queensland, Australia
7 Pain in Motion Research Group, Departments of Human Physiology and Physiotherapy,
Faculty of Physical Education & Rehabilitation, Vrije Universiteit Brussel, Belgium
Address of correspondence and reprints requests to Enrique Lluch Girbés, Department of
Rehabilitation, University of Valencia, Gascó Oliag, 5, 46010 Valencia, Spain (phone
+34963983853; fax +34963983852; e-mail: [email protected])
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ABSTRACT
Background: Apart from the cranio-cervical flexion test and the deep neck flexor
endurance test, evidence related to reliability of cervical movement control dysfunction
tests is lacking.
Objectives: This study investigated the inter- and intra-tester reliability of a battery of
cervical movement control dysfunction tests and the effect of clinician experience on
reliability in 15 patients with chronic neck pain and 17 non-neck pain controls. In
addition, it explored whether impaired performance on this battery of tests was more
frequently observed in the neck pain group.
Design: Inter and intra-tester reliability study.
Method: Participants were videotaped while performing a battery of nine active
cervical movement control dysfunction tests. Two physiotherapists, with different levels
of experience, independently rated all tests on two occasions two weeks apart. They
were masked to participants’ neck pain or non-neck pain status.
Results: Inter-tester reliability for the complete battery of tests was substantial (κ=0.69;
95% CI: 0.62, 0.76). Intra-rater reliability values for the expert (κ=0.86; 95% CI: 0.79,
0.92) and novice (κ=0.76; 95% CI: 0.68, 0.84) were overall comparable suggesting that
novices can achieve good accuracy with the battery of tests if trained. The frequency of
impaired performances in cervical movement control dysfunction tests was low and
comparable between groups. Only two tests achieved a greater number of impaired
ratings in the patient group.
Conclusions: Although reliable, further research in larger neck pain populations is
required to explore this battery of tests, in order to establish their diagnostic accuracy
for identifying clinically relevant cervical movement control dysfunction.
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Keywords: neck pain; movement control tests, reliability
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INTRODUCTION
Neck pain is often a long-standing and recurrent condition (Kjellman et al.,
2001; Carroll et al., 2009). It is estimated that 67% of the population experience neck
pain at some point in their life (Cote et al., 1998), with a higher prevalence in women
(Guez et al., 2002). As pathological mechanisms are frequently difficult to identify,
clinical assessment of impairment and disability has become an accepted approach for
the evaluation of people with neck pain to guide management (Childs et al., 2008).
Analysis of the pattern of neck movement forms part of the assessment to identify
movement faults and assess cervical neuromuscular control (Jull et al., 2004a; Jull et al.,
2008a; Sahrmann 2011; Comerford and Mottram, 2012). These movement faults may
be termed cervical movement control dysfunction (cMCD), consistent with terminology
used for lumbar spine movement dysfunction (Luomajoki et al., 2007). Altered
neuromuscular control of neck movement is considered to be an important factor
contributing to the recurrent nature of neck pain (O’Leary et al., 2009), as it may impose
unwanted stresses on cervical structures (Jull et al., 2008a; Comerford and Mottram,
2012). Consequently, evaluation of cMCD and treatment directed towards its
improvement forms an integral part of diagnosis and management of cervical
musculoskeletal disorders (McDonnell et al., 2005; Childs et al., 2008; Jull et al.,
2008a).
cMCD is defined operationally for the clinical setting as the presence of aberrant
or uncontrolled movements of the cervical spine which are observed during prescribed
active movements of the neck and/or upper limb (Comerford and Mottram, 2012).
Physiotherapists assess cMCD through a series of clinical tests where, through
observation and/or palpation of the cervical spine, the presence of altered movement
control is identified (Jull et al., 2008a; Sahrmann, 2011; Comerford and Mottram,
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2012). Skills may vary between experienced and novice clinicians and thus influence
the decision of whether movements are being performed in a normal or abnormal
manner. Overall, experienced testers have shown better reliability with clinical
screening tests for movement control (Carlsson and Rasmussen-Barr, 2013), albeit this
systematic review pertained to non-specific low back pain. To date, the influence of
examiner experience in the assessment of cMCD has not been explored. Greater
confidence can be had in test reliability if examiner experience is not a factor.
Several tests have been nominated to assess the control of the cervical spine
afforded by the flexor, extensor and rotator muscles (Jull et al., 2008a; Sahrmann, 2011;
Comerford and Mottram, 2012; Elsig et al 2014). Possibly, the most popular test related
to cMCD is the craniocervical flexion test, which was developed to allow clinicians to
assess performance of the deep neck flexor muscles (Jull et al., 2008b). Its face validity
(Falla et al., 2003) and reliability (James and Doe, 2010; Arumugam et al., 2011) has
been demonstrated, although the latter mostly in asymptomatic subjects. However, apart
from this test, evidence related to the reliability of other cMCD tests advocated for use
by clinical experts (Table 1 and Appendix 1) is lacking. In fact, clinical practice
guidelines for neck pain only include the craniocervical flexion test and the test of deep
neck flexor endurance (Harris et al., 2005) as reliable tests for classifying a patient in
the impairment-based category of neck pain with movement coordination impairments
(Childs et al., 2008). This paucity of reliability data for other cMCD tests prompted this
study.
Besides reliability, another clinimetric characteristic is discriminant validity, that
is, the ability of cervical movement control tests to discriminate between patients with
and without neck complaints. A recent systematic review found that the Fly MethodTM,
head repositioning accuracy to the neutral head position and continuous linear
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movement technique are tests of cervical sensorimotor control which have discriminant
validity (Michiels et al., 2013). In addition, a battery of head-eye movement control
tests (Della Casa et al., 2014), the craniocervical flexion test (Elsig et al., 2014) and
three tests evaluating movement control (i.e. cervico-thoracic extension, head
protraction-retraction and quadruped cervical rotation) (Elsig et al., 2014), were also
able to discriminate between cases and controls. However, it is unknown if other tests as
listed in Table 1 can also identify those with and without neck pain.
The primary aim of this study was to determine the inter- and intra-tester
reliability of a battery of selected cMCD tests in a sample of patients with and without
chronic neck pain. In addition, the effect of clinician experience on reliability was
explored. A secondary aim was to make an initial exploration of whether impaired
performance on this battery of cMCD tests was more frequently observed in patients
with neck pain compared to neck pain free participants.
METHODS
Subjects
Thirty-two participants were recruited for the study from two private
physiotherapy practices in Valencia, Spain. Of these, 15 were patients with chronic non-
specific neck pain. To be considered for the study, persons were required to be aged
between 18 and 60 years, have a history of neck pain lasting 3 months or more over the
last year and have a score of ≥ 5/50 on the Neck Disability Index (NDI), to reflect the
presence of at least a mild neck pain disorder (Vernon, 2008). The validated Spanish
version of the NDI was used (Andrade et al., 2010). Patients without neck pain (n=17),
but receiving treatment for other musculoskeletal disorders, were included in the study
to increase the variability in the test sample and, thus, avoid a possible bias by
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considering persons with neck pain only. Subjects in this latter group could not suffer
from any musculoskeletal condition affecting the upper quarter region (i.e. shoulder,
elbow or wrist pain), as this may have altered their performance on the cMCD tests that
require movement or weight bearing of the upper limb.
Individuals were not considered for the study if they had previous cervical spine
surgery, cervical radiculopathy, severe systemic disease (i.e. diabetes), fibromyalgia or
other widespread musculoskeletal pain syndromes (i.e. chronic fatigue syndrome).
Patients with acute neck pain were excluded, as pain may have prevented them from
accomplishing the tests.
All participants received an information leaflet and gave written informed
consent prior to entry into the study. The study was approved by the local Institutional
Ethics Committee and the procedures were conducted according to the Declaration of
Helsinki.
Study design
An inter- and intra-observer reliability study was conducted employing video
analysis as used in a study of movement control tests of the low back (Luomajoki et al.,
2007). Participants were videotaped by an independent researcher in a standardized
manner while they performed a battery of nine active cMCD tests. Two
physiotherapists, with different levels of experience, independently rated all tests. One
had a post-graduate degree in manual therapy and 10 years working experience with the
use of cMCD tests. The other was a novice physiotherapist with a post-graduate degree
and one year of working experience, but with no prior familiarity with the evaluation of
cMCD.
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The test battery
Table 1 and Appendix 1 present the battery of nine tests evaluated in this study.
They were selected based on work by Jull et al (2008a), Sahrmann (2011) and
Comerford and Mottram (2012) and were chosen so that the battery contained tests
which would assess control by the flexor muscles, extensor muscles and directional
control of rotation. Participant’s performance was rated by the examiners as either
correct or impaired, according to operational definitions previously established for each
test (Jull et al., 2008a; Sahrmann, 2011; Comerford and Mottram, 2012). The test of
active cervical extension and return to neutral performed in sitting was divided in two
parts (i.e. test number 4 and 5, Table 1), in order to analyze independently these two
phases of movement.
Procedure
Patients were initially examined by an independent researcher, who assessed
suitability via the inclusion and exclusion criteria and recorded demographic and
anthropometric data of each participant. Thirty patients with chronic non-specific neck
pain were initially screened. Those who met the study requirements (n=15) were then
videotaped while performing each cMCD test. Videotaping (without audio) was
performed by the same independent researcher. The camera was maintained in the same
position at a standardized distance (2 m) and it was ensured that the structures needed
for the interpretation of the tests were visible.
The order of tests was standardized to ensure that all participants were assessed
in the same way and in a manner that paralleled common clinical examination
procedures. All participants received standardized instructions about correct test
performance by the independent researcher who made the video-recording. They were
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then allowed to practice each task with feedback five to eight times prior to video
recording, to ensure they clearly understood what they were required to do. Participants
were then video recorded performing the movement test, without any feedback. This
was the performance rated as correct or impaired by the examiners. Practice sessions
were undertaken as some authors consider that identification of motor control
dysfunction should not be made just on observation of aberrant motion, but on the
patient’s ability to actively and cognitively control or prevent movement (Comerford
and Mottram, 2012 p.48). Therefore, if a patient failed the test it should be because they
could not perform the movement skill and not because they did not understand or had
not learnt what to do. The only tests where practice was not permitted were active
cervical extension and return to neutral in sitting (Jull et al., 2008a), active cervical
flexion in four-point kneeling (Sahrmann, 2011) and rocking backwards in four-point
kneeling (Sahrmann, 2011). Developers of these latter tests advocate that it is necessary
to analyze spontaneous performance. Thus practice was not allowed to conform with
original descriptions of the tests.
Prior to the study, examiners undertook three, 1-hour training sessions with
healthy and neck pain individuals. The expert examiner tutored the novice in the use
and interpretation of the tests as well their categorical performance rating (correct,
impaired) (Table 1).
For the main study, each examiner watched each video recording and recorded
the findings on a data form. The two examiners rated all videos independently and were
masked to each other’s test results and to participants’ status (i.e. with or without neck
pain), to avoid possible bias when rating the tests. The judgment of MCD mostly relies
on visual observation of the quality of movement (Luomajoki et al., 2007). Therefore,
any occasional reproduction of symptoms during the tests was not considered in
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decision making (Hickey et al., 2007). For intra-observer reliability, the two examiners
independently rated the same videos two weeks apart. They were not permitted access
to their data sheets from the first video analysis.
Statistical analysis
Data were analyzed with SPSS 19.0 for Windows. Descriptive statistics were
used to define the demographic characteristics of the sample. Cohen’s kappa (K)
coefficients with 95% confidence intervals (CI) were calculated to determine both intra-
and inter-tester reliability. Specifically, mean Cohen’s K coefficients were calculated
between the two examiners for the complete battery of cMCD tests and for each test
separately, in order to analyze inter-tester reliability. Only scores obtained on
measurement time 1 (day 1) were used to calculate inter-tester reliability. For intra-
tester reliability, mean Cohen’s K coefficients for the complete battery of cMCD tests
and for each test separately, between time 1 (day 1) and time 2 (day 15), were
calculated. A Kappa coefficient of less than 0.01 was considered to reflect poor
agreement, 0.01 to 0.20 slight agreement, 0.21 to 0.40 fair agreement, 0.41 to 0.60
moderate agreement, 0.61 to 0.80 substantial agreement, and 0.81 to 1.00 excellent
agreement (Landis and Koch, 1977).
Intraclass Correlation Coefficients (ICCs) were calculated for each test. ICC
values above 0.75 are considered as excellent reliability, values between 0.40 and 0.75
fair to good, and values below 0.40 poor reliability (Fleiss, 1986).
The frequency of impaired performances assigned in total to a participant by
both examiners on the two assessment sessions (day 1 and day 15), was compared
between the two groups (i.e. subjects with and without neck pain) using t-tests statistics.
Participants could have in total a minimum of 0 and a maximum of 36 impaired cMCD
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tests [9 +9 assigned by examiner 1 on day 1 and 15; 9 + 9 assigned by examiner 2 on
day 1 and 15]. This analysis was conducted to determine whether there were differences
in the frequency of impaired performances for the complete battery of cMCD tests
between participants with and without neck pain.
A second analysis was undertaken to determine the frequency of impaired
performances for each cMCD test assigned to a participant by both examiners on the
two assessment sessions (day 1 and day 15). Participants could have in total a minimum
of 0 and a maximum of 4 impaired performances for each cMCD test [1 +1 assigned by
examiner 1 on day 1 and day 15; 1 + 1 assigned by examiner 2 on day 1 and 15]. This
frequency was compared between the two groups (i.e. subjects with and without neck
pain) through t-tests statistics, in order to determine whether the frequency of impaired
performances for each cMCD test were different between groups.
RESULTS
Participant demographics are presented in Table 2. There were no significant
differences between groups for gender or weight (p>0.05), although the neck pain group
were older and shorter than the group without neck pain (p<0.05).
Intra-tester reliability for the complete battery of cMCD tests was excellent for
the expert examiner (κ=0.86; 95% CI: 0.79, 0.92) and substantial for the novice
(κ=0.76; 95% CI: 0.68, 0.84). There were no significant differences in intra-tester
reliability between examiners (p=0.06). Four of nine tests had almost perfect intrarater
agreement (κ>0.80) and five substantial agreement (κ=0.61-0.80). Active unilateral arm
flexion in standing showed the highest intrarater reliability (κ=0.90; 95% CI: 0.63, 1),
whereas active cervical flexion in four point kneeling showed the lowest κ values,
although still with substantial intrarater agreement (κ=0.70; 95% CI: 0.40, 0.92 for the
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expert examiner; κ=0.70; 95% CI: 0.45, 0.93 for the novice examiner) (Table 3). All
cMCD tests, except rocking backwards in four point kneeling (ICC: 0.49-0.83), showed
excellent reliability (ICCs>0.75). The most reliable test was active cervical rotation in
sitting (ICC: 0.90-0.97) (Table 3).
Inter-tester reliability was substantial (κ=0.69; 95% CI: 0.62, 0.76) for the
complete battery of cMCD tests. Regarding inter-tester reliability for each test, one test
showed excellent (κ>0.80), five substantial (κ=0.61-0.80), one moderate (κ=0.41-0.60)
and two fair interrater agreement (κ=0.21-0.40). Active cervical rotation in sitting was
the most reliable test between examiners (κ=0.81; 95% CI: 0.58, 1). Rocking backwards
in four point kneeling and active unilateral arm flexion in standing were least reliable
with K values of 0.36; 95% CI: 0.12, 0.68 and 0.32; 95% CI: 0.08, 0.63, respectively
(Table 3).
On average, the number of impaired performance ratings out of 36 assigned to a
participant by the two examiners was 13.6 ± 7.4 for patients with chronic neck pain and
10.4 ± 6.1 for the neck pain free participants, and the difference was not significant
(p=0.19). Only the mean number of impaired ratings obtained with tests 1 (active
cervical extension in 4-point kneeling) and 9 (active cervical rotation in sitting), was
significantly greater in subjects with chronic neck pain (p<0.05) (test 1: mean 1.5 ± 1.7
for patients with chronic neck pain and 0.3 ± 1.0 for participants without neck pain; and
test 9, mean 2.7 ± 1.8 for patients with chronic neck pain and 1.2 ± 01.7 for participants
without neck pain). There were no significant differences for the mean number of
impaired ratings for other cMCD tests (all p > 0.05).
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DISCUSSION
This study evaluated the reliability of a battery of tests specifically designed to
evaluate movement control dysfunction of the cervical spine. Intra- and inter-tester
reliability for the complete battery of cMCD tests was shown to be substantial to
excellent. Intra-rater reliability values for the expert and novice were overall
comparable. This suggests that novices can achieve good accuracy with the battery of
tests if trained which concords with conclusions from a recent systematic review on
lumbar MCD tests (Carlsson and Rasmussen-Barr, 2013). Reliability indices for
individual cMCD tests were variable but, in general, better results were obtained for
intra- as compared to inter-rater reliability.
Our findings on reliability are in line with prior work by Luomajoki et al (2007),
who investigated a battery of MCD tests for the lumbar spine. They concluded that
physiotherapists were able to reliably rate most of the lumbar MCD tests by viewing
films of patients with and without back pain. Cohen’s K values for inter- and intra-tester
reliability of the lumbar MDC tests ranged between 0.24-0.71 and 0.51-0.96, which is
very similar to results obtained in the current study (0.32-0.81 and 0.70-0.90 for inter-
and intra-tester-reliability, respectively).
In this study, rocking backwards in four point kneeling and active unilateral arm
flexion in standing were the least reliable tests between examiners. This could be due to
several reasons. For instance, during active unilateral arm flexion in standing, palpation
of cervical spinous processes is recommended to better appreciate the behavior of the
cervical spine (Sahrmann, 2011). However, due to our study design (i.e. video-
recording), only visual observation was used to judge the correctness or not of
movement control. In videotaping the rocking backwards in four point kneeling test, a
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general view was used rather than one focused on the cervical spine as per other cMCD
tests. This could have influenced examiner decision when rating this test.
Frequency of impaired performances for the complete battery of tests and for
most tests individually was comparable between groups. A greater number of impaired
ratings was only identified in the neck pain group for two individual cMCD tests (i.e.
active cervical extension in 4-point kneeling and active cervical rotation in sitting). This
suggests that cMCD tests, although reliable, may not be helpful for detecting persons
with cervical pain. Consistent with our findings, Hickey et al. (2007) investigated
physiotherapists’ accuracy to classify participants as symptomatic or asymptomatic for
shoulder pain based on observation of shoulder movement aberrations. They found that
experienced physiotherapists had difficulty in determining the status of patients by
movement analysis alone (Hickey et al., 2007). In contrast, Luomajoki et al (2008)
found significant differences between patients with and without low back pain in their
ability to actively control movement of the low back. A study by Della Casa et al.
(2014) showed that a head-eye movement control test battery could discriminate
between patients with chronic neck pain and healthy controls. Head-eye movement
control decisions were also based on visual assessment as in the current study. Recently,
Elsig et al (2014) found that three cMCD tests (i.e. cervico-thoracic extension,
protraction-retraction of the head and quadruped cervical rotation) could discriminate
between subjects with neck pain versus controls. Differences in the biomechanics of the
regions under study (cervical vs lumbar spine vs shoulder), in the measures evaluated
(eye vs cervical movement control), or in experimental procedure, may have accounted
for this disparity in results. For instance, Elsig et al (2014) permitted one correction of
performance by the examiner before rating the tests, whereas we used eight practices as
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deemed necessary for patient learning and familiarisation with the test movement
(Comerford and Mottram, 2012. p.57).
The mean number of impaired performances both for the complete battery of
cMCD tests and for each test separately was low in the neck pain group and not
different to the non neck pain group. The exception was a higher frequency of impaired
performance in active cervical extension in 4-point kneeling and active cervical rotation
in sitting in the neck pain group. There could be several reasons for these findings. First,
the observed deviations from the ‘ideal’ observed in the remaining seven tests may not
represent clinically relevant impaired motor control. There is no recognized gold
standard for cMCD on which to judge face validity at this time. Second, our
comparative group without neck pain were attending physiotherapy for other
musculoskeletal disorders. In other words, they were people with movement
dysfunctions in other body regions rather than ‘musculoskeletal healthy’ people which
may have increased the number of impaired movement findings in this group. Third, our
sample reported mild-moderate levels of disability (mean NDI: 13.9 ± 5.6) which could
account for the few impaired performances, as studies have shown associations between
higher levels of pain and disability and greater changes in neuromuscular control (Falla
et al., 2004, 2011; O’Leary et al., 2011). Fourth, as examiners rated performance of
cMCD tests from video recordings, they were masked to the patients’ symptom
responses and history, which does not replicate the clinical setting. Others have used
information from the patients’ symptoms during such tests (Van Dillen et al., 2003;
2009) and consideration of symptom reproduction during the tests may be an essential
element of assessment. Finally, it is known that there is a large variability of motor
impairments in people with neck pain (Lindstroem et al., 2012; Schomacher et al.,
2013).Very likely the results of the current study were affected by the inclusion of
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patients with neck pain but without major neuromuscular impairments. Greater support
for the cMCD tests would have likely occurred if only patients with indications of
movement coordination impairments were selected (Childs et al., 2008).
As an additional note, postural deficits (i.e. thoracic kyphosis) were not
specifically addressed prior to movement testing and thus may have confounded the
results of some cMCD tests, such as active cervical rotation in sitting (Quek et al.,
2013).
The results of this study could suggest that reducing the battery of cMCD tests to
those two tests which were different between the neck pain and non-neck pain groups
(i.e. active cervical extension in 4-point kneeling and active cervical rotation in sitting)
might be the logical future direction. However this is probably premature. Further
research is needed to explore these tests, probably in real time, in other and larger neck
pain groups to explore their diagnostic accuracy (i.e. sensitivity, specificity) for
identifying a cMCD. It could also be questioned whether tests of rocking backwards in
four point kneeling and active unilateral arm flexion in standing should be eliminated
from the battery of test because of poor inter-tester reliability. This needs to be
investigated in future studies which do not introduce potential errors identified in video
analysis. Alternately, research may be directed towards developing and investigating
other tests for identifying impairments in cervical movement control.
Conclusion
Physiotherapists can achieve substantial to excellent intra- and inter-tester
reliability when analyzing cervical movement control dysfunction, through the battery
of tests used in this study. However, when used in isolation, this battery of tests did not
distinguish between the neck and non-neck pain groups in our sample. Further research
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is needed to explore the validity of this battery of cMCD tests in patients with neck
pain.
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Appendix 1: Cervical Movement Control Dysfunction (cMCD)
Tests
cMCD test 1: Active cervical extension in 4-
point kneeling
cMCD test 2: Active upper cervical rotation in
4-point kneeling
cMCD test 3: Active cervical flexion in 4-point
kneeling
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extension and return to neutral in sitting
cMCD test 6: Active bilateral arm flexion in
standing
cMCD test 7: Rocking backwards in 4-point
kneeling
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cMCD test 8: Active unilateral arm
flexion in standing
cMCD test 9: Active cervical rotation in
sitting
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Table 1: Operational definitions for the movement control tests of the cervical spine
MOVEMENT CONTROL TESTS MUSCLES/ DIRECTION OF
MOVEMENT CONTROL
CORRECT IMPAIRED PERFORMANCE
1) Active cervical extension in 4-point kneeling (Jull et al., 2008a) * Instruction: “Imagine you have a book between your hands. Look down to flex the head and neck together as far as you can and then curl your head back up as far as you can (lower and mid cervical spine), but maintain your eyes on the book” The patient is to perform cervical extension, while keeping the cranio-cervical region in neutral.
Bias towards semispinalis cervicis/multifidus which act only on the cervical spine and against superficial extensors, which also extend the head
Patient is able to dissociate mid-lower from upper cervical extension: head remains in a neutral position whilst performing mid-lower cervical extension to about 20 degrees
Patient is unable to dissociate mid-lower from upper cervical extension. Different impairments can be observed: The patient cannot reach 20 degrees of cervical extension while keeping the cranio-cervical region in neutral The patient adopts a poor coordination strategy and uses superficial cervical muscles excessively, indicated by cranio-cervical extension (poked chin). and excessive use of the semispinalis capitis muscles indicated by their marked prominence on the back of the neck.
2) Active upper cervical rotation in 4-point kneeling (Jull et al., 2008a) * Instruction: “Rotate the head whilst keeping the cervical region still, as if saying ‘No’ ” Therapist gently stabilizes the C2 vertebra (only for the practice sessions) to assist in locating the movement to the upper cervical region. Patient is instructed to perform small ranges of cranio-cervical rotation to both sides (no greater than 40º), while maintaining cervical spine in a neutral position.
Bias towards the suboccipital rotators (obliquus capitis superior and inferior)
Patient is able to dissociate upper cervical rotation movement from movement at the mid-lower cervical region: no motion of the mid-lower cervical spine occurs.
Patient is unable to dissociate upper cervical rotation movement from movement at the typical cervical region: excessive motion of the typical cervical region occurs.
3) Active cervical flexion in 4-point kneeling (Sahrmann,2011)
Extensor muscles The flexion movement is predominantly anterior
Movement: The head and the cervical spine translate anteriorly with diminished anterior sagittal plane rotation
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Instruction: “look down to flex the head and neck together as far as you can”
sagittal plane rotation of the head and cervical spine.
during the flexion movement. Lower cervical flexion greater than upper thoracic flexion.
4) Active cervical extension in sitting (Jull et al., 2008a) Instruction: “look towards the ceiling and follow the ceiling back with the eyes as far as possible”
Flexors muscles (eccentric control)
Head extends behind the frontal plane to 15-20º. A pattern of smooth and even neck extension of upper, mid and lower cervical regions should be observed.
Dominant upper cervical spine extension with minimal, if any, movement of the head posteriorly. The head moves backward but then reaches a point of extension where it appears to drop or translate backwards.
5) Return to neutral from the cervical extension position in sitting (Jull et al., 2008a) Instruction: “Return to neutral from the cervical extension position”
Flexor muscles (concentric control)
Return to neutral position starts with craniocervical flexion followed by lower cervical flexion.
Initiation of returning to neutral position with sternocleidomastoid and anterior scalene muscles resulting in lower cervical flexion but not upper cranio-cervical flexion. Craniocervical flexion is the last rather than first component of the pattern of movement.
6) Active bilateral arm flexion in standing (Commerford and Mottram, 2012)* Instruction: “Raise and lower your arms (palms in) as far as you can keeping your head steady”
Flexor, extensor muscle co-contraction
Cervical spine remains still during 180º of bilateral arm flexion
Compensatory/excessive forward head movement or extension of the cervical spine observed during 180º of bilateral arm flexion.
7) Rocking backwards in 4-point kneeling (Sahrmann, 2011) Instruction: “Rock backwards slowly as far as you can”
Flexor, extensor muscle co-contraction
Cervical spine remains in a neutral position during the movement.
Compensatory motion or excessive cervical extension is observed during the quadruped rocking back
8) Active unilateral arm flexion in standing (Sahrmann, 2011)* Instruction: “Raise and lower each arm separately (palm in) as far as you while keeping the head in a neutral position”
Flexor, extensor muscle co-contraction
Cervical spine remains stable via observation during single-arm flexion to 180º to both sides
Compensatory motion of cervical rotation/lateroflexion is noted during arm flexion to 180º in either side
9) Active cervical rotation in sitting (Sahrmann, 2011)*
Rotation movement control
A pattern of smooth and even head rotation around
Rotation to either side occurs with concurrent/simultaneous lateral flexion, extension or flexion and/or forward
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Instruction: “Rotate your head and neck as far as you can to each side while maintaining the plane of the face vertical and eyes horizontal. Note: bilateral cervical rotation is assessed with the scapula in a neutral position (hands on thighs)
a vertical axis should be observed to each side (70-80º rotation to each side). The plane of the face should stay vertical with the eyes horizontal and with concurrent upper and lower cervical movement. No other components of motion (i.e. lateroflexion, extension or flexion) should be observed.
translation of the head and neck.
*In these tests, participants received standardized instructions regarding the correct performance of the test, and were allowed to practice with therapist feedback for correct performance up to five to eight repetitions prior to video recording.
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Participants without
neck pain Participants with chronic neck pain
P value
N=32
17
15
Age (years) 23.9 ± 3.9
37.9 ± 9.76
P<0.05
Gender (male/female)
58.8%/41.2%
26.7%/75.3%
P>0.05
Weight (Kg)
70.3 ± 7.9
66.7 ± 15.5
P>0.05
Height (cm) 174.4 ± 10.1
166.1 ± 8.3
P<0.05
Average duration of neck pain (months)
___ 48.3 ± 72.9
NDI (0-50) ___
13.9 ± 5.6
*NDI, Neck disability Index
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Table 3. Mean Cohen’s κ values and Intraclass Correlation Coefficients (ICCs) with 95% confidence intervals (CIs) of each cervical movement control dysfunction (cMCD) test.
Test Active cervical
extension in 4 point
kneeling
Active upper
cervical rotation in
4 point kneeling
Active cervical
flexion in 4 point
kneeling
Active cervical
extension in sitting
Active return to
neutral from extension in
sitting
Active bilateral
arm flexion in standing
Rocking backwards in
4 point kneeling
Active unilateral
arm flexion in standing
Active cervical
rotation in sitting
Results inter-observer reliability
Mean Kappa
0.67 (0.33-0.95
0.80 (0.66-0.93)
0.52 (0.22-0.81)
0.73 (0.29-0.91)
0.69 (0.44-0.90)
0.71 (0.44-0.93)
0.36 (0.12-0.68)
0.32 (0.08-0.63)
0.81 (0.58-1)
Results intra-observer reliability
Mean Kappa (expert examiner)
0.86 (0.66-1)
0.80 (0.55-1)
0.70 (0.40-0.92)
0.74 (0.49-0.94)
0.87 (0.68-1)
0.78 (0.53-0.98)
0.80 (0.54-1)
0.90 (0.63-1)
0.81 (0.55-1)
Mean Kappa (novice examiner)
0.84 (0.53-1)
0.79 (0.54-0.99)
0.70 (0.45-0.93)
0.71 (0.44-0.93
0.85 (0.64-1)
0.77 (0.52-0.97)
0.78 (0.54-0.99)
0.89 (0.69-1)
0.80 (0.55-1)
ICCs 0.92
(0.86-0.95) 0.94
(0.90-0.97) 0.85
(0.75-0.92) 0.91
(0.85-0.95) 0.82
(0.87-0.96) 0.93
(0.88-0.96) 0.70
(0.49-0.83) 0.79
(0.62-0.89) 0.94
(0.90-0.97)