Accepted Manuscript

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: enrique.lluch@uv.es)

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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)