Reliability and Validity of Clinical Tests to Assess
Posture, Pain Location, and Cervical Spine Mobility
in Adults with Neck Pain and its Associated Disorders:
Part 4. A Systematic Review from the Cervical Assessment
and Diagnosis Research Evaluation (CADRE) CollaborationThis section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
FROM: Musculoskeletal Science & Practice 2018 (Dec); 38: 128–147 ~ FULL TEXT
N. Lemeunier, E.B. Jeoun, M. Suri, T. Tuff, H. Shearer, S. Mior, J.J. Wong, S. da Silva-Oolup, P. Torres, C. D'Silva, P. Stern, H. Yu, M. Millan, D. Sutton, K. Murnaghan, P. Coté
UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation,
University of Ontario Institute of Technology (UOIT),
2000, Simcoe St. N.,
Oshawa, Ontario, Canada.
nlemeunier@ifec.net.
PURPOSE: To determine the reliability and validity of clinical tests to assess posture, pain location, and cervical spine mobility in adults with grades I–IV neck pain and associated disorders (NAD).
METHODS: We systematically searched electronic databases to update the systematic review of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders. Eligible reliability and validity studies were critically appraised using modified versions of the QAREL and QUADAS-2 instruments, respectively. Evidence from low risk of bias studies were synthesized following best evidence synthesis principles.
RESULTS: We screened 14,302 articles, critically appraised 46 studies, and found 32 low risk of bias articles (14 reliability and 18 validity studies). We found preliminary evidence of:1) reliability of visual inspection, aided with devices (CROM and digital caliper) to assess head posture;
2) reliability and validity of soft tissue palpation to locate tender/trigger points in muscles;
3) reliability and validity of joint motion palpation to assess stiffness and pain provocation in combination; and
4) range of motion tests using visual estimation (in cervical extension only) or devices (digital caliper, goniometer, inclinometer) to assess cervical mobility.
There are more articles like this @ our:
CHIROPRACTIC SUBLUXATION PageCONCLUSIONS: We found little evidence to support the reliability and validity of clinical tests to assess head posture, pain location and cervical mobility in adults with NAD grades I–III. More advanced validity studies are needed to inform the clinical utility of tests used to evaluate patients with NAD.
KEYWORDS: Neck pain; Palpation; Physical examination; Range of motion; Reliability; Systematic review; Validity; Visual inspection
From the FULL TEXT Article:
INTRODUCTION:
Several tests are available to inspect, determine pain location, and assess the mobility of patients with neck pain and its associated disorders (NAD). However, the clinical utility of these tests remains unclear. In 2008, the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders (NPTF) systematically reviewed the literature [1] (Table 1). The NPTF found little evidence that inspection, palpation, and range of motion provide valid information to clinicians. Since the NPTF publication, other systematic reviews reported on the reliability and validity of palpation and range of motion measurement [2–6], but their conclusions are conflicting.
We aimed to update the NPTF systematic review on the diagnosis and assessment of NAD and conducted a best-evidence synthesis to determine the reliability and validity of clinical tests used for the inspection, palpation, and assessment of cervical spine mobility in adults with NAD [1]. This review is the fourth in a series of five systematic reviews updating the NPTF on assessment of patients with NAD [7–11]. Together, these reviews will inform the development of a clinical practice guideline for the clinical assessment of NAD.
METHODS
Registration
We registered our review with the International Prospective Register of Systematic Reviews (PROSPERO) on February 2, 2016 (CRD4201603XXXX), (CRD420160XXXX), (CRD420160XXXXX).
Eligibility CriteriaPopulation We included studies of adults with grade I–IV NAD, including Whiplash-associated Disorders (WAD) grades I–IV (Online Appendix 1) [12–13].
Definitions We restricted our review to studies assessing reliability and validity of posture, pain location, and cervical mobility. Reliability describes the consistency of measurements across people or instruments [14]. Validity is the degree to which a test measures what it is intended to measure [14].
Visual inspection tests aim to document visible defects, general positioning and posture, functional deficits and deformities or lesions detectable by the eye with or without the assistance of devices [14]. Static manual palpation is used to localize bony landmarks, joint stiffness, tender points, and trigger points to evaluate tissue texture, temperature, tone, bony positioning, and pain [15]. Motion palpation aims to evaluate joint movement within the normal range of motion or within the boundaries of the paraphysiological range [15]. Finally, range of motion is the arc through which movement occurs at a joint or series of joints [16], and can be active or passive [6].
Study Characteristics Eligible for our review were: 1) English or French peer-reviewed publications; 2) reliability or validity studies; and 3) studies of adults (≥18 years) with grades I–IV NAD or WAD. We excluded: 1) guidelines, letters, editorials, commentaries, unpublished manuscripts, dissertations, government reports, books and book chapters, conference proceedings, meeting abstracts, lectures and addresses, consensus development statements, guideline statements; 2) literature reviews and case series; 3) cadaveric or animal studies; 4) studies restricted to grade IV NAD; 5) studies with < 20 participants/group; 6) studies assessing nonmanual palpation (e.g., pressure algometry); or 7) studies of devices not used in routine clinical practice (e.g., 3D measurement system).
Data Sources and Searches
Our search strategy was developed with a health sciences librarian and reviewed by a second librarian. We searched MEDLINE, PubMed, CINAHL, and the Cochrane Central Register of Controlled Trials from January 1, 2005 to November 7, 2017 using specific search strategies (Online Appendix 2A – 2C). We also searched SPORTDiscus for manual palpation. Search terms included subject headings and free text words. Our search strategy include combined the following terms “neck pain” OR “whiplash” OR “cervical spine”; “visual inspection” OR “palpation” OR “range of motion”; and “reliability” OR “validity” OR “diagnosis”. These terms were combined using the Boolean operator [AND]and [NOT] “animals”. We restricted our search to French and English articles. We developed the search in MEDLINE through clinical EBSCOhost Online, and subsequently adapted it to the other databases.
Study Selection
Pairs of trained reviewers independently screened citations in two sequential stages. Stage 1 involved screening of titles and abstracts. Possibly relevant citations were screened independently in stage 2 using the full text article. Reviewers met to reach consensus and resolve disagreements after each stage of independent review. A third reviewer independently screened the citation and determined eligibility if consensus could not be reached.
Assessment of Risk of Bias
Pairs of independent reviewers critically appraised the relevant studies. We assessed internal validity using the modified Quality Appraisal Tool for Studies of Diagnostic Reliability (QAREL) [18] criteria for diagnostic reliability studies and the modified Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) criteria for diagnostic accuracy/validity studies [19]. We modified the original QAREL and QUADAS-2 instruments to include:].1) a question on clarity of study objectives;
2) a “not applicable” option for items 3, 4, 5, 6, and 8 in QAREL, and 3.1, 3.2, 3.3 and 3.B in QUADAS-2; and
3) the Sackett and Haynes classification (in the QUADAS-2 instrument) [20Consensus was reached between reviewers. An independent third reviewer resolved disagreements. Study authors were contacted for methodological clarification, if necessary. Studies with adequate internal validity (i.e., low risk of bias) entered our best evidence synthesis [21].
Data Extraction and Synthesis of Results
One reviewer extracted data from low risk of bias studies and a second reviewer verified its accuracy (Online Appendix 3 and 4). We stratified NAD as recent-onset (<3 months), persistent (≥3 months), or variable duration (combined recent-onset and persistent). Furthermore, we stratified studies according to purpose (inspection, palpation, range of motion) and Sackett and Haynes classification [20] (Online Appendix 5).
Statistical Analyses
We computed the inter-rater reliability for article screening using the kappa coefficient (κ) and 95% confidence intervals (CI) [22]. We calculated the percentage agreement for classifying high or low risk of bias studies following critical appraisal.
Reporting
Our review complies with the Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [23] and Statement for Reporting Studies of Diagnostic Accuracy (STARD) [24].
RESULTS
Study Selection
In total, for the three search strategies, we screened 14302 citations, of which 14256 were ineligible (three studies were ineligible after contacting authors [25–27]). We critically appraised 46 articles and 32 had a low risk of bias. Some of these 32 articles overlapped between the three topics leading to 26 low risk of bias articles in total [28–53] (Figures 1A, 1B and 1C). The inter-rater agreement for screening was: 1) k=0.76 (95% CI: 0.67–0.84) for visual inspection; 2) k=0.78 (95% CI 0.70–0.87) for palpation; and 3) k=0.85 (95% CI: 0.79– 0.97) for range of motion. The total percentage agreement for the three critical appraisals was 89% (41/46). One disagreement required a third reviewer.
Study Characteristics
Fifteen studies investigated reliability [30–34; 40–47; 50; 52] and
18 assessed validity [28–29; 32–39; 44; 47–53] (Online Appendix 3 and 4).
The low risk of bias studies evaluated:1) visual inspection (8 studies) [28–34, 50];
2) soft tissue palpation (4 studies) [37; 39–41];
3) static and motion joint palpation (9 studies) [35–36; 38–44]; and
4) range of motion (14 studies) [30–31; 37; 40–41; 44–49; 51–53].
Risk of Bias for Studies
All reliability studies with low risk of bias had appropriate research questions, patient selection, test application, test interpretation, and statistical measure of agreement (Online Appendix 6).
However, studies had limitations related to:1) selection of examiners [33, 47];
2) blinding of examiners [31; 33–34; 40–47; 50; 52]; and
3) interval between assessments [34; 41, 45].All low risk of bias validity studies used an appropriate reference standard, and prespecified threshold for interpretation of the reference standard (Online Appendix 7).
However, studies had limitations related to:1) sampling [29; 32; 34–35; 37; 47–48; 50–52];
2) blinding of examiners [32, 35; 38; 44; 49]; and
3) time interval between index and reference tests [32, 34, 36–39; 44; 47–49].Two reliability [50–51] and five validity studies had high risk of bias [56–60].
The reliability studies had limitations related topatient selection [50–51],
rater’s blinding [50],
time interval [50–51], and
the index test [50–51].The five validity studies had limitations related to
selection and flow of participants [56–60],
blinding of examiners [53],
reference test and time interval [54].
Summary of Evidence
ReliabilityInspection of Posture in Patients with NAD I–III The evidence suggests that visually inspecting forward head posture has poor reliability (inter-rater reliability –0.10≤k≤0.05) [30–31] (Table 2). However, forward head posture can be measured with less error than with inspection when using goniometer, digital caliper or inclinometer, and Head Posture Spinal Curvature Instrument device (inter-rater reliability 0.62≤ICC≤0.95; intra-rater reliability 0.64≤ICC≤0.98) [32–34; 50]. The evidence suggests that excessive or decreased thoracic kyphosis cannot be reliably assessed with visual inspection and may be associated with inconsistency of measurement (inter-rater reliability –0.10≤k≤0.9) (Table 2) [30–31]. However, excessive scapular protraction can be assessed through visual inspection (inter-rater reliability 0.70≤k≤0.83) [30–31] (Table 2).
Manual Palpation in Patients with NAD I–III The inter-rater reliability of manual palpation of the cervical spine is inconsistent. There is inconsistency of measurement associated with segmental examination (C2–7) using joint static palpation to identify pain in patients with NAD I–II (inter-rater reliability 0.32≤k≤0.66) [41]. However, tenderness over C1 transverse processes can be assessed with less measurement error (inter-rater reliability k=0.83 (95% CI: 0.74–0.92)) with joint static palpation [44] (Table 2).
Important variability exists in the inter-rater reliability of joint motion palpation when using joint end-feel to assess segmental stiffness (inter-rater reliability 0.25≤k≤0.77) [42–43]. However, one study suggested that combined joint segmental stiffness and pain can be reliably assessed using posterior-anterior motion palpation of the C2–7 facet joints (inter-rater reliability 0.74≤k≤0.96; intra-rater reliability 0.63≤k≤0.88) [40] (Table 2). We found inconsistent evidence from two low risk of bias studies that muscle palpation is reliable to assess tender points in cervical muscles (Table 2) [40–41]. Schneider et al. (2013) reported that segmental tender points in the para-spinal muscles (C2–C7) can be reliably assessed in patients with NAD I–II (inter-rater reliability 0.74≤k≤0.96; intra-rater reliability 0.51≤k≤0.84) with soft tissue palpation [40] (Table 2). However, another study reported inconsistency of measurement with muscle palpation when assessing tender points in cervical muscles (i.e., trapezius or levator scapulae inter-rater reliability 0.36≤k≤0.52; splenius or semispinalis inter-rater reliability 0.33≤k≤0.62) in patients with NAD I–II [41] (Table 2).
Cervical Range of Motion in Patients with NAD I–III The evidence suggests that visually estimating active and passive cervical flexion, rotation, and lateral flexion is inconsistent (inter-rater reliability 0.23≤k≤0.77) [41; 46] (Table 2). However, the measurement of active and passive cervical extension through visual estimation is consistent (inter-rater reliability 0.76≤k≤0.80) [41; 46] (Table 2). Evidence suggests that measuring active range of motion with an inclinometer, goniometer or iPhone with a G-pro application can be done reliably (inter-rater reliability 0.65≤k≤0.95; intrarater reliability 0.62≤k≤0.97) in patients with NAD I–II [30–31; 40; 44–45; 47; 52]. These results differ from studies targeting patients with NAD I–III (inter-rater reliability of inclinometers or goniometers 0.31≤k≤0.75) [30–31; 40; 45; 47] (Table 2).
ValidityInspection of Posture in Patients with NAD I–III One phase I study suggests that inspecting upper thoracic and craniovertebral posture/angles using photographic measurement while sitting at a computer should differentiate those with persistent NAD I–II from healthy people. However, no evidence was found for shoulder posture using the same technique [28] (Table 3).
There is inconsistent evidence about the ability of three devices (CROM device, Digital Caliper, or goniometer) to distinguish differences in head posture between patients with NAD I–III (craniofacial related pain, pain intensity, and disability) compared to healthy participants [29; 32–34; 50]. Similarly, two studies (phase I and II) provide conflicting evidence that head posture measured with the CROM device and Digital Caliper differs between patients with NAD I–II and healthy controls [29; 32] (Table 3). In contrast, one phase I and two phase II studies provide preliminary evidence that head posture measured with goniometers and inclinometers differs between patients with NAD I–II and healthy controls [33–34; 50]. Patients with NAD I–III had greater craniovertebral angles for forward head posture compared to asymptomatic age-matched controls and this was associated with increased perceived disability [33–34]. However, the correlation between craniovertebral angle and neck pain intensity in patients with NAD I–III was not statistically significant [34] (Table 3).
Manual Palpation in Patients with NAD I–III Evidence from one phase I–II study suggests that patients with NAD II had more trigger points identified by static palpation in the temporalis, upper trapezius, sternocleidomastoid, levator scapula, scalene, and suboccipital muscles compared to healthy controls [37]. Moreover, the number of active trigger points was positively correlated with pain intensity, but negatively correlated with cervical range of motion and pain pressure thresholds at C5–6 [37]. One phase II study investigated the validity of static palpation to identify localized paraspinal muscle tenderness from C2–7 and reported a sensitivity of 94% and specificity of 73% when compared to facet joint blocks [39] (Table 3).
The validity of joint motion palpation to identify the presence of hypomobility, pain reproduction, abnormal joint end-feel, and resistance varies across four phase I and II studies [35–36; 38–39]. In patients with NAD I/II, the presence of a trigger point in the upper trapezius is correlated with ipsilateral cervical dysfunction at C3 and C4 (p<0.03) [36]; however, the strength of the correlation is not known (Table 3).
Two phase II studies used medial branch nerve blockades as a reference standard for facet joint pain following motion palpation assessment of the cervical spine [38–39]. Sensitivity ranged from 89% to 92% and specificity ranged from 47% to 71% [38–39]. Specificity increased to 75% when joint palpation was combined with paraspinal segmental muscle tenderness [39] (Table 3).
One phase II study investigated the validity of joint motion palpation for identifying intervertebral restriction in patients with NAD I–III [35]. Quantitative fluoroscopy was used as a reference standard to measure inter-vertebral range of motion in the sagittal plane during cervical flexion and extension. Agreement between palpation findings and quantitative fluoroscopy was low (k=0.06) [35] (Table 3).
Cervical Range of Motion in Patients with NAD I–III Four phase I and six phase II studies suggest that assessing cervical range of motion using devices (such as goniometers, inclinometers, or iPhone with a G-Pro application) may be a valid test to assess cervical mobility [37; 44; 47–49; 51–52]. Compared to individuals without neck pain, patients with acute NAD I–II have reduced active cervical range of motion [48; 51– 52]. Specifically, patients with neck pain had a mean reduction that ranged from 8.7 degrees in total lateral flexion [48] to 29.2 degrees in extension [37] compared to those without neck pain (Table 3). However, the evaluation of range of motion may not vary between patients with subacute NAD I–II and healthy controls [48]. In patients with acute NAD II, active cervical range of motion is negatively correlated with neck disability, catastrophizing and number of active trigger points [37; 44; 51]. Similarly, in patients with persistent NAD I–III, active cervical range of motion is negatively correlated with neck disability, pain intensity, physical health-related quality of life, and non-organic pain behavior [47; 49] (Table 3).
DISCUSSION
Summary of Results
Overall, we found little evidence to support the reliability and validity of clinical tests to assess head posture, pain location, and cervical mobility in adults with NAD grades I–III. Few low risk of bias studies have been published since the NPTF in 2008 [1] (Table 1). However, our findings support, and augment the results of the NPTF by providing further preliminary evidence, supported by phase I and II studies, for the palpation of soft tissue tender points, and joint motion palpation for segmental stiffness, hypomobility, pain provocation, and joint pain. [38–43]
New preliminary evidence (phases I and II) suggests that range of motion may help discriminate between patients with acute NAD I–II from asymptomatic controls . [48; 51–52]
However, the evaluation of range of motion may not vary between patients with subacute NAD I–II and healthy controls [48]. We also found new evidence that decreased active cervical range of motion is correlated with lower levels of neck disability and pain intensity, and better physical health-related quality of life in patients with persistent NAD I–III [47; 49]. Finally, our review also agrees with recent reviews that external devices may be superior to visual estimation in measuring cervical range of motion [30–34; 37; 40; 44–45; 47–49; 51–53]. The absence of a true gold standard, and the lack of knowledge about a patho-anatomical source of pain poses an important methodological challenge to the study of diagnostic tests for NAD. Although facet joint blocks are the most widely used approach to diagnosing facet joint pain [61], there is controversy about its validity [62]. Similarly, although quantitative fluoroscopy offers a reliable measure of inter-vertebral range of motion [63], it has not been validated nor extensively utilized in the cervical spine [35].
Strengths and Limitations
Our review has several strengths. First, we developed a comprehensive search strategy of multiple databases in consultation with two health sciences librarians. Second, we used clear, predefined inclusion and exclusion criteria to identify a broad range of possibly relevant citations. Third, we used multiple pairs of trained, independent reviewers to screen and critically appraise citations to minimize bias and error. Furthermore, we minimized bias in reported results by performing a best-evidence synthesis that included only low risk of bias studies [21]. Finally, we classified the validity studies according to the Sackett and Haynes definition, which provides evidence of the stage of investigation and degree of confidence that can be placed on specific studies [20].
Our review has limitations. First, we limited our search to studies published in the English and French language. Although previous reviews suggest that English language limiters do not produce bias in reported results [64–68], some relevant studies may have been excluded. Second, our search strategy may not have retrieved all relevant studies. Third, we limited our search to studies published after 2004. However, previous studies were likely captured by the NPTF. Finally, individual differences in scientific judgement may result in varied critical appraisal outcomes among reviewers. To minimize this bias, reviewers were trained using standardized assessment tools and completed a consensus process for determining scientific admissibility.
Clinical Implications
We found few reliable and valid clinical tests to assess pain location and cervical spine mobility in adults with NAD. Overall, the evidence is preliminary at best, supported by phase I and II validity studies from the Sackett and Haynes classification [20]. Clinicians must consider the preliminary nature of the evidence when recommending static soft tissue palpation for the localization of tender points in muscles, joint motion palpation when segmental stiffness and pain provocation are assessed in combination, visual inspection of posture with a digital caliper or goniometer, and active or passive range of motion tests using visual estimation (for cervical extension only) or devices (e.g., goniometer, inclinometer). Finally, we found no evidence that any of the clinical tests affects clinical outcomes related to NAD.
CONCLUSION
We found limited evidence to support the use of clinical tests to evaluate pain location and cervical mobility. The evidence is at best preliminary for a few tests. Clinicians have very few valid and reliable clinical tests to evaluate patients and arrive at a useful diagnosis. This highlights the importance of a thorough clinical history to exclude red flags and avoid misdiagnosing of patients with neck pain. Future research needs to address this important gap.
Acknowledgement:
The authors acknowledge and thank Mrs. Sophie Despeyroux, librarian at the Haute Autorité de Santé, for her suggestions and review of the search strategy. This research was undertaken, in part, thanks to funding from the Canada Research Chairs program to Dr. Pierre Côté, Canada Research Chair in Disability Prevention and Rehabilitation at the University of Ontario Institute of Technology.
Conflict of Interest
The authors declare that they have no conflict of interest.
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