Research Review By Dr. Brynne Stainsby©


Download MP3

Date Posted:

August 2019

Study Title:

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) collaboration


Lemeunier N, Jeoun EB, Suri M, Tuff T et al.

Author's Affiliations:

Institut Franco-Européen de Chiropraxie, Toulouse, France; UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation University of Ontario Institute of Technology (UOIT), Oshawa, Canada; Graduate Education and Research, Canadian Memorial Chiropractic College (CMCC), Toronto, Canada; Rehabilitation Centre, San Cristobal Clinic, Santiago Spine Group, Santiago, Chile; Library, Canadian Memorial Chiropractic College (CMCC), Toronto, Canada; Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), Oshawa, Canada; Cabinet d’expertise medicale, Castres, France.

Publication Information:

Musculoskeletal Science and Practice 2018; 38: 128-147.

Background Information:

As neck pain and its associated disorders (NAD) are common complaints, several tests are available to help clinicians determine the location of pain and assess mobility in these patients. In addition to defining grades of NAD I-IV for diagnostic purposes, The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders (NPTF) found little evidence that inspection, palpation and assessment of range of motion (ROM) actually provide valid information to clinicians (1).

The aim of this CADRE review was to update the NPTF systematic review on the diagnosis and assessment of NAD and provide a best evidence synthesis to determine the reliability and validity of clinical tests used in adults with NAD, specifically those used to assess posture, pain location and cervical mobility.

Pertinent Results:

Literature Search Results & Study Characteristics:
  • A total of 14 302 citations were screened for eligibility, resulting in 46 articles being critically appraised.
  • Twenty-six articles were found to have low risk of bias and included in the review (2-27).
  • Fifteen studies investigated reliability (4-8, 14-21, 24, 26) and 18 studies assessed validity (2, 3, 6-14, 18, 21-27).
  • Eight studies assessed visual inspection (2-8, 24); four studies assessed soft tissue palpation (11, 13-15); nine studies assessed static and motion joint palpation (9, 10, 12-18) and 14 studies assessed ROM evaluation (4, 5, 11, 14, 15, 18-23, 25-27).
Reliability of Clinical Testing & Procedures:
  • The evidence suggests that in patients with NAD I-III, visually inspecting forward head posture has poor reliability (inter-rater reliability −0.10 ≤ k ≤ 0.05) (4, 5), but can be measured with less error when using a goniometer, digital caliper, inclinometer or Head Posture Spinal Curvature Instrument device (inter-rater reliability 0.62 ≤ ICC ≤0.95; intra-rater reliability 0.64 ≤ ICC ≤ 0.98) (6-8, 24). The evidence suggests that thoracic kyphosis cannot reliably be assessed with visual inspection (inter-rater reliability −0.10 ≤ k ≤ 0.9) (4, 5), however it is possible to observe excessive scapular protraction through visual inspection (inter-rater reliability 0.70 ≤ k ≤ 0.83) (4, 5).
  • In patients with NAD I-II, static joint palpation to identify pain has been found to be inconsistent (inter-rater reliability 0.32 ≤ k ≤ 0.66) (15), however tenderness over the C1 transverse process can be assessed with less measurement error (inter-rater reliability k = 0.83 [95% CI: 0.74–0.92]) (18).
  • When using joint motion palpation to assess joint end-feel and segmental stiffness, variability exists in the literature (inter-rater reliability 0.25 ≤ k ≤ 0.77) (16, 17), but then combined with pain, one study suggested it can be reliably assessed in the C2-7 facet joints (inter-rater reliability 0.74 ≤ k ≤ 0.96; intra-rater reliability 0.63 ≤ k ≤ 0.88) (14). There is inconsistent evidence regarding the reliable assessment of tender points with soft tissue palpation (inter-rater reliability 0.74 ≤ k ≤ 0.96; intra-rater reliability 0.51 ≤ k ≤ 0.84 for cervical paraspinal muscles) (14), trapezius or levator scapulae (inter-rater reliability 0.36 ≤ k ≤ 0.52); splenius or semispinalis (inter-rater reliability 0.33 ≤ k ≤ 0.62) (15).
  • The evidence suggests that visually estimating active and passive flexion, rotation and lateral flexion ROM in patients with NAD I-III is inconsistent (inter-rater reliability 0.23 ≤ k ≤ 0.77) (15, 20), however the measurement of active and passive cervical extension is consistent (inter-rater reliability 0.76 ≤ k ≤ 0.80) (15, 20). The evidence suggests that measuring active cervical ROM with devices such as an inclinometer or goniometer can be done reliably (inter-rater reliability 0.65 ≤ k ≤ 0.95; intra-rater reliability 0.62 ≤ k ≤ 0.97) (4, 5, 14, 18, 19, 21, 26).
Validity of Clinical Testing & Procedures:
  • The evidence from one phase I study suggests that inspecting upper thoracic and craniovertebral posture while sitting at the computer (using photographic measurements) should differentiate those with persistent NAD I-II from healthy subjects (2). There is inconsistent evidence, however, regarding the abilities of the CROM device, digital caliper or a goniometer to distinguish differences in head posture between healthy subjects and those with NAD I-III (3, 6, 7, 8, 24).
  • The evidence suggests that static palpation of the cervical musculature identified more trigger points in patients with NAD II than in healthy controls, and the number of active trigger points correlated positively with pain intensity, but correlated negatively with cervical ROM and pain-pressure thresholds (11). Additionally, when compared to facet joint blocks, static palpation was able to identify localized paraspinal muscle tenderness with a sensitivity of 94% and specificity of 73% (13). When motion palpation was compared to facet joint blocks, sensitivity ranged from 89% to 92% and specificity ranged from 47% to 71% (12,13), but specificity was increased to 75% when combined with paraspinal segmental muscle tenderness (13). Agreement was low (k = 0.06) when motion palpation was compared with quantitative fluoroscopy to identify intervertebral motion restrictions. (9).
  • The evidence suggests devices such as goniometers, inclinometers or new iPhone applications may be valid in the assessment of cervical mobility in patients with NAD I-III (11, 18, 21-23, 25, 26). When compared to subjects without neck pain, patients with acute NAD I-II have reduced active cervical ROM (22, 25, 26), and in these patients, active cervical ROM is negatively correlated with neck disability, catastrophizing and the number of active trigger points (11, 18, 25). In patients with persistent NAD I-III, active cervical ROM is negatively correlated with neck disability, pain intensity, physical health-related quality of life and non-organic pain behavior (21, 23).

Clinical Application & Conclusions:

Although this review found little evidence to support the reliability and validity of common clinical tests to assess posture, pain location and cervical mobility in adults with NAD I-III, the findings do support and expand on the work of the NPTF (1). The additional evidence included in this review suggests that ROM may help to discriminate between patients with acute NAD I-II from asymptomatic controls, and that higher active cervical ROM is correlated with lower levels of disability and pain intensity, and better health-related quality of life in patients with persistent NAD I-III.

With the lack of a single clinical ‘gold standard’, clinicians should be encouraged to integrate findings, and when possible, assess for pain in addition to clinician’s assessment of palpation. As always, the findings of this review suggest that physical examination findings should be used in the context of ruling in or out differential diagnoses, after performing a careful history and ruling out red flags. Though not included in this particular review, clinicians should always be reminded of the importance of performing a neurological examination for patients with NAD.

Study Methods:

  • A systematic search strategy was developed in consultation with a health sciences librarian and reviewed by a second librarian.
  • Four databases were searched from January 1st, 2005 to November 7th, 2017 using appropriate search terms for each database. An additional database (SPORTDiscus) was searched specifically for manual palpation. Reference lists of included studies and related systematic reviews were screened for additional resources.
  • Pairs of independent authors screened titles and abstracts for relevant and possibly relevant citations, which were reviewed using the full text. Reviewers met to reach consensus and a third reviewer independently determined eligibility if consensus could not be reached.
  • Only reliability or validity studies published in English or French in a peer-reviewed journal which included samples of 20 or more adult participants (per group) with grades I-IV NAD or WAD were included in this review. Included studies must have assessed the validity or reliability of posture, pain location and cervical mobility.
  • Pairs of independent authors appraised all relevant studies using the modified Quality Appraisal Tool for Studies of Diagnostic Reliability (QAREL) (28) for diagnostic reliability studies and the modified Quality Assessment of Diagnostic Accuracy Studies-2 (29) for diagnostic accuracy/validity studies. Reviewers met to reach consensus and a third reviewed independently determined eligibility if consensus could not be reached. Studies with low risk of bias were included in the best evidence synthesis.
  • One reviewer extracted data from low risk of bias studies and built evidence tables. A second reviewer verified the accuracy of the data.
  • Inter-rater reliability for article screening with the kappa coefficient and 95% confidence intervals were calculated for percentage agreement for classifying high or low risk of bias studies.
  • A qualitative synthesis (best evidence synthesis) was then performed.

Study Strengths / Weaknesses:

  • A clearly defined research question with a thorough and systematic search.
  • Independent screening of titles and abstracts, and full texts.
  • Reviewers were trained using the standardized assessment tools and consensus was used to determine admissibility.
  • Assessment of risk of bias was performed with a validated set of criteria.
  • Only those trials assessed as being of high quality were included.
  • Two authors independently extracted the data from the included articles.
  • Validity studies were classified based on the Sackett and Hayes definition (30), to provide evidence of the stage of investigation.
  • This study used the principles of best evidence synthesis to inform scientific judgment and resultant clinical recommendations.
  • The primary limitation of this study relates more to the quality of the body of evidence than the methodology of the review itself.
  • Although previous reviews suggest that English language limiters do not produce bias, it should be noted that this review was limited to studies published in English and French, so it is possible relevant studies may have been missed (31-35).
  • While only studies with low risk of bias were included, the reliability studies had limitations related to selection or blinding or examiners, and the interval between assessments, and the validity studies had limitations related to sampling, blinding of examiners and the time between index and reference tests.

Additional References:

  1. 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. Spine 2008; 33(4 Suppl. l): S101–S122.
  2. Nejati P, Lotfian S, Moezy A et al. The study of correlation between forward head posture and neck pain in Iranian office workers. Int J Occup Med Environ Health 20015; 28(2): 295–303.
  3. Dunleavy K, Neil J, Tallon A et al. Reliability and validity of cervical position measurements in individuals with and without chronic neck pain. J Man Manip Ther 2015; 23(4): 188–196.
  4. Cleland JA, Childs JD, Frit, JM et al. Interrater reliability of the history and physical examination in patients with mechanical neck pain. Arch Phys Med Rehabil 2006; 87(10): 1388–1395.
  5. Hanney WJ, George SZ, Kolber MJ et al. Inter-rater reliability of select physical examination procedures in patients with neck pain. Physiother Theor Pract 2014; 27(2): 345–352.
  6. Lopez-de-Uralde-Villanueva I, Beltran-Alacreu H, Paris-Alemany A et al. Relationships between craniocervical posture and pain-related disability in patients with cervico-craniofacial pain. J Pain Res 2015; 8: 449–458.
  7. Nilsson B, Söderlund A. Head posture in patients with whiplash-associated disorders and the measurement method's reliability – a comparison to healthy subjects. Adv Physiother 2005: 7(1): 13–19.
  8. Yip CHT, Chiu TTW, Poon ATK. The relationship between head posture and severity and disability of patients with neck pain. Man Ther 2008; 13(2): 148–154.
  9. Branney J, Breen AC. Changes in inter-vertebral range of motion after spinal manipulation: a prospective cohort study. Chiropr Man Ther 2014; 22(1): 24.
  10. Fernandez de las Penas C, Fernandez Carnero J, Miangolarra Page J. Musculoskeletal disorders in mechanical neck pain: myofascial trigger points versus cervical joint dysfunction - a clinical study. J Muscoskel Pain 2005; 13(1): 27–35.
  11. Fernández-Pérez AM, Villaverde-Gutiérrez C, Mora-Sánchez A et al. Muscle trigger points, pressure pain threshold, and cervical range of motion in patients with high level of disability related to acute whiplash injury. J Orthop Sports Phys Ther 2012; 42(7): 634–641.
  12. King W, Lau P, Lees R et al. The validity of manual examination in assessing patients with neck pain. Spine J 2007; 7 (1): 22–26.
  13. 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 Rehabil 2014; 95(9): 1695–1701.
  14. 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.
  15. Maigne JY, Chantelot F, Chatellier G. Interexaminer agreement of clinical examination of the neck in manual medicine. Ann Phys Rehabil Med 2009; 52(1): 41–48.
  16. Bakhtadze M, Patijn J, Galaguza VN et al. Inter-examiner reproducibility of the segmental motion palpation springing test for side bending at level C2-C3. Int. Musculoskelet Med 2011: 33(1): 8–14.
  17. Manning D, Dedrick G, Sizer P et al. Reliability of a seated three-dimensional passive intervertebral motion test for mobility, end-feel, and pain provocation in patients with cervicalgia. J Man Manip Ther 2012; 20(3): 135–141.
  18. Piva SR, Erhard RE, Childs JD et al. Inter-tester reliability of passive intervertebral and active movements of the cervical spine. Man Ther 2006; 11(4): 321–330.
  19. Fletcher JP, Bandy WD. Intrarater reliability of cervical range of motion measurement of cervical spine active range of motion in persons with and without neck pain. J Orthop Sports Phys Ther 2008; 38 (10): 640–645.
  20. Hoppenbrouwers M, Eckhardt MM, Verkerk K et al. Reproducibility of the measurement of active and passive cervical range of motion. J Manip Physiol Ther 2006; 29(5): 363–367.
  21. Jorgensen R, Ris I, Falla D et al. Reliability, construct and discriminative validity of clinical testing in subjects with and without chronic neck pain. BMC Muscoskel Disord 2014; 15: 408.
  22. Ang BO. Impaired neck motor function and pronounced pain-related fear in helicopter pilots with neck pain - a clinical approach. J Electromyogr Kinesiol 2008; 18(4): 538–549.
  23. Vernon H, Guerriero R, Kavanaugh S et al. Self-rated disability, fear-avoidance beliefs, nonorganic pain behaviors are important mediators of ranges of active motion in chronic whiplash patients. Disabil Rehabil 2013; 35(23): 1954–1960.
  24. Alahmari K, Reddy RS, Silvian P et al. Intra- and interrater reliability of neutral head position and target head position tests in patients with and without neck pain. Braz J Phys Ther 2017; 21(4): 259–267.
  25. Muñoz-García D, Gil-Martínez A, López-López A et al. Chronic neck pain and cervico-craniofacial pain patients express similar levels of neck pain-related disability, pain catastrophizing, and cervical range of motion. Pain Res Treat 2016; 7296032.
  26. Pourahmadi MR, Bagheri R, Taghipour M et al. A new iPhone application for measuring active craniocervical range of motion in patients with non-specific neck pain: a reliability and validity study. Spine J 2018; 18(3): 447–457.
  27. López-de-Uralde-Villanueva I, Acuyo-Osorio M, Prieto-Aldana M et al. Reliability and minimal detectable change of a modified passive neck flexion test in patients with chronic nonspecific neck pain and asymptomatic subjects. Musculoskel Sci Pract 2017; 28: 10–17.
  28. Lucas N, Macaskill P, Irwig L et al. The reliability of a quality appraisal tool for studies of diagnostic reliability (QAREL). BMC Med Res Methodol 2013; 13: 111.
  29. Whiting PF, Rutjes AW, Westwood ME et al. Group Q-: QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med 2011; 155(8): 529–536.
  30. Sackett DL, Haynes RB. The architecture of diagnostic research. BMJ 2002; 324(7336): 539–541.
  31. Juni P, Holenstein F, Sterne J et al. Direction and impact of language bias in meta-analyses of controlled trials: empirical study. Int J Epidemiol 2002; 31: 115–123.
  32. Moher D, Fortin P, Jadad AR et al. Completeness of reporting of trials published in languages other than English: implications for conduct and reporting of systematic reviews. Lancet 2996; 347: 363–366.
  33. Moher D, Pham B, Lawson ML et al. The inclusion of reports of randomized trials published in languages other than English in systematic reviews. Health Technol Assess 2003; 7: 1–90.
  34. Morrison A, Polisena J, Husereau D et al. The effect of English-language restriction on systematic review-based metaanalyses: a systematic review of empirical studies. Int J Technol Assess Health Care 2012; 28: 138–144.
  35. Sutton AJ, Duval SJ, Tweedie RL et al. Empirical assessment of effect of publication bias on meta-analyses. BMJ 2000; 320: 1574–1577.