Research Review By Dr. Brynne Stainsby©


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Date Posted:

September 2017

Study Title:

Reliability and validity of clinical tests to assess the anatomical integrity of the cervical spine in adults with neck pain and its associated disorders: Part 1 – A systematic review from the Cervical Assessment and Diagnosis Research (CADRE) Collaboration


Lemeunier N, da Silva-Oolup S, Chow N et al.

Author's Affiliations:

Institut Franco-Europe´en de Chiropraxie, Toulouse, France; UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology, Oshawa, ON, Canada; Graduate Education and Research, Canadian Memorial Chiropractic College, Toronto, ON, Canada; Clinical Education, Canadian Memorial Chiropractic College, Toronto, ON, Canada; Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, ON, Canada; Occupational and Industrial Orthopaedic Centre, Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY, USA; School of Public Health, University of Alberta, Edmonton, AB, Canada; Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, ON, Canada.

Publication Information:

European Spine Journal; 2017; 26(9): 2225-2241.

Background Information:

Neck pain (NP) and its associated disorders (NAD) are common in the general population, such that more than 80% of people experience NAD in their lifetime and up to 50% of adults report NP annually (1, 2). Although most NP is benign, it is essential to reach an accurate diagnosis to inform management and prognosis, given the possibility that patients may be presenting with serious underlying pathology (3).

Previous systematic reviews have found limited evidence to support the use of clinical tests in assessing the cervical spine (4, 5). Specifically, the Neck Pain Task Force (NPTF, published in 2008) conducted a systematic review regarding the assessment and diagnosis of neck pain and found three studies evaluating the validity of tests that assess the anatomical integrity of the cervical spine (6-9). These studies reported variable sensitivities for Spurling’s test and the upper limb neurodynamic/tension tests when compared to gold standards (MRI, nerve conduction studies, electromyography and myelography) and did not find studies reporting on the reliability of these tests (6). These authors did not report on clinical tests that are used to detect vascular lesions in the arteries of the cervical spine, and the use of Doppler velocimetry remains controversial (10-18).

This systematic review is the first in a series of five updating the NPTF (6). The purpose of these reviews is to inform the development of a clinical practice guideline for the assessment of the cervical spine, and the purpose of this review specifically is to update the findings of the NPTF regarding the reliability and validity of clinical tests used to assess the anatomical integrity of the cervical spine in adults with NAD.

Pertinent Results:

Summary of Critical Appraisal

This review screened 9022 citations and critically appraised eight articles. All eight articles had a low risk of bias and were included in the review (19-26). Three studies evaluated reliability (19, 23, 24). All three assessed inter-examiner reliability and one assessed intra-examiner reliability (19). Five studies reported on validity (20-22, 25, 26). Three were Phase II studies (20, 22, 25) and two were Phase III (21, 26).

With respect to the specific clinical tests studied:
  • Two studies assessed the cervical extension-rotation test (19, 20)
  • Four studies assessed Spurling’s test (22-25)
  • Two studies assessed the components of a neurological examination (21, 24)
  • Two studies assessed the reliability of upper limb tension tests (23, 24)
  • One study assessed the validity of upper limb neurodynamic tests (26)
  • No article studying Doppler velocimetry for the assessment of cervical artery vascular lesions in patients with NAD was found
Summary of Reliability Studies
  • Evidence from one study (19) suggests the cervical extension-rotation test has adequate reliability to detect pain originating in the facet joints.
  • Evidence from two studies (23, 24) suggests that in patients with persistent NAD (grades I-III), the reliability of upper limb neurodynamic, upper limb tension tests and Spurling’s test is inadequate and may actually result in misclassification of patients.
  • Evidence from one study (24) suggests that in adult patients with persistent NAD (grades I-III), the inter-examiner reliability of manual motor testing and dermatomal sensory testing is likely associated with patient misclassification.
Summary of Validity Studies
  • Evidence from one Phase II study (20) suggests the cervical extension-rotation test has a sensitivity of 82.7% (95% CI 70.3-90.6) and a specificity of 58.9% (95% CI 47.5-69.5) when compared to the reference standard of a medial branch block to evaluate pain suspected of originating in the facet joint. When combined with manual spinal examination and palpation for tenderness, the specificity improved to 83.4% (95% CI 73.4- 90.3), while the sensitivity decreased to 77.4% (95% CI 64.5-86.6).
  • Two Phase II studies (22, 25) assessed the validity of Spurling’s test for the assessment of nerve root compression. One suggested the sensitivity and specificity were 95% and 94%, respectively (22). The other assessed six variations of the test and found that combining extension, lateral flexion and axial compression elicited more arm pain and more distal pain (25).
  • One Phase III study (26) assessed cervical nerve root compression using upper limb neurodynamic tests and found the sensitivity and specificity to be 97% (95% CI 85-99) and 69% (95% CI 61-100), respectively.
  • One Phase III study (21) suggests the sensitivity and specificity of neurological examination (manual muscle testing, dermatomal sensory testing, deep tendon and pathological reflexes) to be 83% (95% CI 55-95) and 28% (95% CI 15-46), respectively.

Clinical Application & Conclusions:

This review updated the findings of the NPTF regarding the reliability and validity of clinical tests used to assess the anatomical integrity of the cervical spine in adults with NAD. The evidence suggests that a clinician’s primary responsibility is to rule out serious pathology by conducting a thorough history to identify any red flags.

As much of the evidence on the assessment of the cervical spine is preliminary, very few physical examination tests can be used for adults with NAD. Clinical tests that do not have evidence of reliability and validity should not be used, as they may lead to misdiagnosis and potentially, mismanagement. The results of this review suggest that the extension-rotation test, Spurling’s test, upper limb neurodynamic tests and a neurological exam (motor testing, sensory testing, deep tendon reflexes and pathological reflexes) may be useful, depending on the differential diagnosis.

Study Methods:

  • Because this article synthesizes evidence from three systematic reviews, three systematic search strategies were developed in consultation with a health sciences librarian and reviewed by a second librarian.
  • The review targeted reliability or validity studies of clinical tests for the assessment of adults with NAD and WAD (grades I-IV).
  • MEDLINE, CINAHL and the Cochrane Central Register of Controlled Trials, SportsDiscus and PubMed were searched.
  • Two authors independently screened titles and abstracts for inclusion through a two-stage screening process.
  • Two authors then independently appraised the methodological quality of eligible articles. The modified Quality Appraisal Tool for Studies of Diagnostic Reliability was used to appraise the quality of reliability studies, and the modified Quality Assessment of Diagnostic Accuracy Studies-2 was used to appraise validity studies. Reviewers met to reach consensus and a third reviewer was used to resolve disagreements.
  • Studies with a low risk of bias were included in the best evidence synthesis.
  • Included studies were classified into categories to determine how a clinical test had been examined to establish its clinical utility. Phases I and II indicate preliminary evidence of utility, while Phases III and IV are required to inform validity and utility in clinical practice.
  • One reviewer extracted data from high-quality guidelines and built evidence tables. A second reviewer confirmed the data.
  • Best evidence (qualitative) synthesis was performed to develop evidence statements given the heterogeneity of the included studies.
  • Inter-reviewer agreement (kappa coefficient with 95% confidence intervals) was calculated for article screening and admissibility.
  • The review was organized and reported based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement (27) and Statement for Reporting Studies of Diagnostic Accuracy (STARD) (28).

Study Strengths / Weaknesses:

  • A clearly defined research question and study population with a thorough and systematic search.
  • Independent screening of titles and abstracts, and full texts.
  • Assessment of methodological quality (risk of bias) was performed using relevant and validated sets of criteria.
  • Only those trials assessed as being of high quality were included.
  • In addition to methodological quality, clinical utility was also assessed.
  • Two authors independently screened, assessed and extracted the data from the included articles.
  • Qualitative synthesis was performed to develop evidence statements given the heterogeneity of the data.
  • Inter-reviewer agreement was calculated for article admissibility.
  • Strengths and limitations of the review are documented.
  • The primary limitation of this study relates more to the quality and quantity of the body of evidence than the methodology of the review itself.
  • Although the authors used a validated tool to assess risk of bias, critical appraisal requires scientific judgment and can vary between reviewers (though consensus discussion was used to resolve disagreement).

Additional References:

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  2. Cote P, Cassidy JD, Carroll L. The Saskatchewan health and back pain survey: the prevalence of neck pain and related disability in Saskatchewan adults. Spine 1998; 23(15): 1689–1698.
  3. Newman TB, Kohn MA. Evidence-based diagnosis. Cambridge University Press 2009; Cambridge.
  4. Hutting N, Scholten-Peeters GG, Vijverman V et al. Diagnostic accuracy of upper cervical spine instability tests: a systematic review. Phys Ther 2013; 93(12): 1686–1695.
  5. Stuber K, Lerede C, Kristmanson K et al. The diagnostic accuracy of the Kemp’s test: a systematic review. J Can Chiropr Assoc 2014; 58(3): 258.
  6. Nordin M, Carragee EJ, Hogg-Johnson S et al. Assessment of neck pain and its associated disorders: results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders. J Manip Physiol Ther 2009; 32(2): S117–S140.
  7. Wainner RS, Fritz JM, Irrgang JJ et al. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine 2003; 28: 52–62.
  8. Viikari-Juntura E, Porras M, Laasonen EM. Validity of clinical tests in the diagnosis of root compression in cervical disc disease. Spine 1989; 14:253–257.
  9. Sandmark H, Nisell R. Validity of five common manual neck pain provoking tests. Scand J Rehabil Med 1995; 27: 131–136.
  10. Spurling RG, Scoville WB. Lateral rupture of the cervical intervertebral discs: a common cause of shoulder and arm pain. Surg Gynecol Obstet 1944; 78: 350–358.
  11. Butler DS. The upper limb tension test revisited. In: Grant R (ed) Clinics in physical therapy. Physical therapy of the cervical thoracic spine, 2nd edn. 1994. Churchill Livingstone, Edinburgh, pp 217–244.
  12. Davidson RI, Dunn EJ, Metzmaker JN. The shoulder abduction test in the diagnosis of radicular pain in cervical extradural compressive monoradiculopathies. Spine 1981; 6(5): 441–446.
  13. Rubinstein SM, Pool JJM, van Tulder MW et al. A systematic review of the diagnostic accuracy of provocative tests of the neck for diagnosing cervical radiculopathy. Eur Spine J 2007; 16(3): 307–319.
  14. Rubinstein SM, van Tulder MW. A best-evidence review of diagnostic procedures for neck and low-back pain. Best Pract Res Clin Rheumatol 2008; 22(3): 471–482.
  15. Arnetoli G, Armadori A, Stefani P et al. Sonography of vertebral arteries in De Kleyn’s position in subjects and in patients with vertebrobasilar transient ischaemic attacks. Angiology 1989; 40: 716–720.
  16. Kaneda H, Irano T, Miname T et al. Diagnostic reliability of the percutaneous ultrasonic Doppler technique for vertebral arterial occlusive disease. Stroke 1977; 8: 571–579.
  17. Hennerici M, Aulich A, Sandman W et al. Incidence of asymptomatic extracranial arterial disease. Stroke 1981; 12: 751–757.
  18. Ringelstein EB, Zeumer H, Poek K. Non-invasive diagnosis of intracranial lesions in the vertebrobasilar system. A comparison of Doppler sonographic and angiographic findings. Stroke 1985; 5: 848–855.
  19. Schneider GM, Jull G, Thomas K et al. Intrarater and interrater reliability of select clinical tests in patients referred for diagnostic facet joint blocks in the cervical spine. Arch Phys Med Rehabil 2013; 94(8): 1628–1634.
  20. Schneider GM, Jull G, Thomas K et al. Derivation of a clinical decision guide in the diagnosis of cervical facet joint pain. Arch Phys Med Rehab 2014; 95(9): 1695–1701.
  21. Inal EE, Eser F, Aktekin LA et al. Comparison of clinical and electrophysiological findings in patients with suspected radiculopathies. J Back Musculoskelet Rehabil 2013; 26(2):169–173.
  22. Shabat S, Leitner Y, David R, Folman Y. The correlation between Spurling test and imaging studies in detecting cervical radiculopathy. J Neuroimaging 2012; 22(4): 375–378.
  23. Hanney WJ, George SZ, Kolber MJ et al. Inter-rater reliability of select physical examination procedures in patients with neck pain. Physiother Theory Pract 2014; 30(5): 345–352.
  24. Schmid X, Brunner F, Luomajoki H et al. Reliability of clinical tests to evaluate nerve function and mechanosensitivity of the upper limb peripheral nervous system. BMC Musculoskelet Disord 2009; 10: 11.
  25. Anekstein Y, Blecher R, Smorgick Y et al. What is the best way to apply the Spurling test for cervical radiculopathy? Clin Orthop Relat Res 2012; 470(9): 2566–2572.
  26. Apelby-Albrecht M, Andersson L, Kleiva IW et al. Concordance of upper limb neurodynamic tests with medical examination and magnetic resonance imaging in patients with cervical radiculopathy: a diagnostic cohort study. J Manip Physiol Ther 2013; 36(9):626–632.
  27. Moher D, Liberati A, Tetzlaff J et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med 2009; 151: 264[W64]–269[W64].
  28. Bossuyt P, Reitsma J, Bruns D et al. Towards complete and accurate reporting of studies of diagnostic accuracy: the STARD initiative. Ann Clin Biochem 2003; 40: 357–363.