- Email: [email protected]
Reproducibility of the Measurement of Active and Passive Cervical Range of Motion
REPRODUCIBILITY OF THE MEASUREMENT OF ACTIVE AND PASSIVE CERVICAL RANGE OF MOTION Mirrin Hoppenbrouwers, PT,a Martine M.E.M. Eckhardt, PT,b Karin Verkerk, MSc,c and Arianne Verhagen, PhDd
ABSTRACT Objective: The primary aim of this study was to assess the reproducibility of tests for the active and passive range of motion used in the physical examination for patients with neck pain. The secondary aim was to determine whether the history of the patients influences the reproducibility and the prevalence of positive findings. Methods: Sixty-nine participants were recruited in 3 physical therapy practices. Two examiners independently performed a physical examination on all participants. The examiners were blinded for patient characteristics (neck pain/no neck pain) and each other’s findings. History findings were available for only half the patients with neck pain. Cohen’s j was used to express reproducibility. Results: The reproducibility for active and passive range of motion was moderate (j = 0.52 and 0.54, respectively), but a wide range in j scores was found. Extension of the neck showed good reproducibility for both active and passive movements (j = 0.88 and 0.85), whereas lateral flexion showed poor reproducibility (j = 0.35 and 0.33). Knowledge of history had no influence on the reproducibility and prevalence of positive findings. Conclusion: The reproducibility for active and passive range of motion is moderate. Knowledge of the patient’s history did not influence the reproducibility and prevalence of positive findings. (J Manipulative Physiol Ther 2006;29:363-367) Key Indexing Terms: Reproducibility of Results; Cervical Vertebrae; Neck Pain; Range of Motion; Articular; Physiotherapy
N
eck pain is a common problem in The Netherlands with a prevalence of 20.6%.1 Approximately one third of these patients visit a physiotherapist for treatment. There is an increased interest in scientific studies concerning the effectiveness of physiotherapy. As a result, the need for reproducible methods of physical examination in patients with neck pain increases. There are just a few studies that evaluate the validity or reproducibility of physical examination procedures in patients with neck pain.2 For instance, Bertilson et al3 investigated the reliability of a range of clinical tests used in the examination of patients with neck pain and the influence of knowledge about patients’ medical histories on outcomes. In this study, the assessment of active and passive range of motion showed moderate reproducia
Hogeschool Rotterdam, Rotterdam, The Netherlands. Hogeschool Rotterdam, Rotterdam, The Netherlands. c Assistant Professor, Department of Physiotherapy, Hogeschool Rottterdam, Rotterdam, The Netherlands. d Epidemiologist and Senior Researcher at the Department of General Practice, Erasmus Medical Centre, University Rotterdam, The Netherlands. Submit requests for reprints to: Martine M.E.M. Eckhardt, PT, Rochussenstraat 728, 3015 ZG Rotterdam, The Netherlands (e-mail: [email protected]). Paper submitted June 3, 2005; in revised form November 11, 2005. 0161-4754/$32.00 Copyright D 2006 by National University of Health Sciences. doi:10.1016/j.jmpt.2006.04.007
bility with a j value of 0.29 for the examination without knowledge of the patient’s history and 0.27 with knowledge of the patient’s history. They concluded that knowledge of history did not affect the reliability of these tests. In physiotherapy, the selection of treatment is based on 2 sources, namely, history findings and physical examination. In physiotherapy, there are tests used, which have not been tested for reliability, or tests that are considered to be nonreliable. However, the conclusions based on the outcomes of these tests are used to make a treatment plan. The primary aim of this study was to assess the reproducibility of tests for active and passive range of motion used in the physical examination by a physiotherapist for patients with neck pain. The secondary aim was to determine whether the knowledge of the history of the patients influenced the reproducibility and prevalence of positive findings.
b
METHODS Design The current study is a test-retest design that took place between March 29, 2004, and May 7, 2004, in 2 physical therapy practices in Rotterdam and a health care center in Zwijndrecht, The Netherlands.
Study Population Patients asked to participate in this study were those who (1) had discomfort or pain localized in the cervical region 363
364
Hoppenbrouwers et al Reproducibility of Range of Motion
(C0-T4) with or without radiation to the shoulder or arm; (2) were between 18 and 65 years of age; and (3) who could read and understand the Dutch language. These patients were designated bneck pain patients.Q We also included people without neck pain as healthy subgroup. We excluded people with malignancies, fractures in the neck/shoulder region, congenital deformities of the cervical spine, patients with balance disorders, migraine, or patients who had undergone surgery in the cervical spine. All participants received a letter with information about the study, and then they gave oral and written consent to participate in the study. Procedures used were in accordance with the standards of the Medical Ethical Committee of the ErasmusMC, Erasmus Medical Center University.
Examiners The investigation was done by 2 physiotherapy students (MH and ME), who were in the last year of their study at Hogeschool Rotterdam, The Netherlands.
Procedure An independent physiotherapist of the participating practices arbitrarily clustered the neck pain patients into 1 of 2 groups. Group 1 included patients with neck pain of which the history was not revealed to the examiners, and group 2 included patients with neck pain whose history was known by the examiners before the physical examination. A third group included people without neck pain whose history was not revealed to the examiners. The independent physiotherapists received numbered envelopes, which included a letter with information about the study and the questionnaires. The envelopes for group 2 were marked with a cross. When the examiners received an envelope with a cross, they were able to look at the patient’s history before performing the physical examination. When they received an envelope without a cross, only the physical examination was carried out. The examiners were therefore blinded for the characteristics of people in groups 1 and 3.
Questionnaires Two questionnaires, an overall questionnaire and the Neck Disability Index (NDI), evaluated the history of the patients. The overall questionnaire consisted of 17 questions, developed by the examiners, that evaluated demographic data, the nature of the neck pain complaints, and some questions concerning the general health. The questionnaire mirrored the questions asked during a patient history normally carried out during the physiotherapeutic intake. The NDI consists of 10 questions to determine the disabilities a patient experiences in daily life due to neck pain. The NDI has appeared to be reliable and valid.4,5 All patients with neck pain filled in both questionnaires before the examination. The people without neck pain only filled in the demographic data and the questions about general health on the overall questionnaire.
Journal of Manipulative and Physiological Therapeutics June 2006
Physical Examination The physical examination consisted of 6 active and 6 passive movements to examine the range of movement of the cervical spine (C0-T4). These movements were flexion, extension, left and right rotation, and left and right lateral flexion. The tests were carried out and judged by a standardized procedure, as described by Dos Winkel who is a Dutch teacher in physical examination.6 For all assessment, the participants were in an active sitting position. For the active movements, the participants were instructed to make pure flexion, extension, rotation, and lateral flexion movements. For the passive movements, the examiners placed one hand on the head to guide the different movements and the other hand on the trunk for fixation. Every movement was carried out twice by each examiner and classified as normal or restricted. The second measurement was taken for the analysis; the first one was considered as a warming up movement. Flexion was considered restricted if the distance from the chin to the incisura jugularis was more than 2 cm. Extension was judged to be restricted if the plane line extending from the nose to the forehead did not reach the horizontal. Rotation and lateral flexion were judged by the difference between left and right. When one movement appeared to be more limited than the other this movement was defined as restricted. For rotation, the distance from the chin to the acromion was compared between left and right. The lateral flexion was judged by comparing the distance from the ear to the acromion at the left and the right side.6 In addition to these standardized judging methods, an implicit method, based on the examiners experience and considering sex, age, and race of the patient, was used to determine a normative value for the movements of rotation and lateral flexion.7,8 The 2 examiners performed pilot examinations on 15 fellow students to establish a similar examination procedure and criteria for the classification of the clinical findings. The examiners independently performed the physical examinations in a random sequence and did not inform the patients on the outcomes of the examination to prevent passing information to the second examiner.
Statistics Reproducibility was determined by calculation of Cohen’s j.9 A j value of 0.20 and smaller was considered to be poor, 0.21 to 0.40 to be moderate, 0.41 to 0.60 to be reasonable, 0.61 to 0.80 to be good, and higher than 0.81 to be very good.10 The prevalence of positive findings during the examination was also determined. The number of positive findings was defined as the sum of restricted movements found by the 2 examiners. The absolute number of positive findings was converted to a percentage per group.
Journal of Manipulative and Physiological Therapeutics Volume 29, Number 5
Hoppenbrouwers et al Reproducibility of Range of Motion
Table 1. Characteristics of the participants Group 1
Group 2
Table 3. Reproducibility per group Group
j active ROM4
j passive ROM4
Patients without neck pain Neck pain patients without history Neck pain patients with history
0.46 0.48 0.48
0.29 0.55 0.58
Group 3
Count Total Men/women
25 10/15
23 2/21
21 11/10
4 This j value is calculated including all movements.
Mean (SD) Age
43.0 (10.9)
Duration of complaints
Count
Acute (0-2 wk) Subacute (2 wk-3 mo) Chronic (N3 mo)
1
1
Group
2
2
22
20
Participation problems
Mean (SD)
NDI score (0-50)
11 (7.0)
17 (8.1)
1 Active Passive 2 Active Passive 3 Active Passive
Count4 4
1
14
7
5
11
1
3
0
1
No disability44 Mild disability Moderate disability Severe disability Complete disability Amount of pain
Mean (SD)
VAS score (0-100)
42.3 (23.3)
45.4 (11.3)
38.7 (11.7)
Table 4. Positive findings during testing Count of positive findings
Percent of positive findings
175 158
29.2 26.3
162 150
30.7 27.2
74 61
14.7 12.1
RESULTS Participants
42.0 (26.3)
4 In group 1 there is 1 missing value concerning the NDI score. 44 NDI classification by Vernon and Mior 5.
A total of 74 people were asked to participate in the current study. One person did not participate because of acquaintance with the examiners and another person was sick on the arranged examination date. Three people were excluded because of rheumatoid arthritis. Eventually, 69 people participated in this study; characteristics of the participants are shown in Table 1. The mean age of the participants was 42.5 years. Most patients with neck pain had chronic neck pain; only 6 people had acute or subacute neck pain. In group 2, most participants had a moderate disability score, whereas in group 1, mild disability was most common.
Reproducibility Table 2. Reproducibility per movement (n = 69) j active and passive ROM
Movement
j active ROM
j passive ROM
Flexion Extension Rotation (left/right) Lateral flexion (left/right)
0.57 0.88 0.49 (L: 0.43/R: 0.54) 0.35 (L: 0.33/R: 0.36)
0.77 0.85 0.51 (L: 0.47/R: 0.54) 0.33 (L: 0.23/R: 0.43)
0.65 0.87 0.50
All movements together
0.52
0.54
0.53
0.33
The j values for reproducibility are shown in Tables 2 and 3. The percentage of agreement for all active and passive range of motions between the 2 examiners was 78.2%. The reproducibility for active and passive range of motion was moderate (j = 0.53). We found a wide range in j values between the different movements. Extension showed good reproducibility for both the active and passive movements, whereas lateral flexion showed poor reproducibility for the active and passive movements. Overall, the reproducibility for the active and passive movements was similar, except for flexion; here the j value for the active movement showed a considerably lower value than the one for passive movement. This study showed no distinct influence of knowledge of the subjects’ histories on the reproducibility.
365
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Hoppenbrouwers et al Reproducibility of Range of Motion
Positive Findings We determined the percentage of positive findings for all examined groups (Table 4). There was no apparent difference in the percentage of positive findings between neck pain patients based upon the examiners possessing knowledge of the participants’ histories (groups 1 and 2). In 12% to 15% of the tests on subjects without neck pain, a restricted movement of the neck was found.
DISCUSSION The overall active and passive examination of the neck had a reasonable reproducibility, with a j value of 0.53. There was no difference in the reproducibility or positive findings between the groups, with or without knowledge of patients’ histories. Our results were not comparable with earlier studies. A study carried out by Bertilson et al3 showed only a moderate reproducibility for active range of motion, whereas we found a reasonable reproducibility. The current study shows, however, that knowledge of a patient’s history has no influence on the reproducibility; this is similar to Bertilson et al.3 In a study carried out by Viikira-Juntura.11 the reproducibility was determined for the different movements of the examination of the active range of movement. Their j values for left and right rotation (0.40 and 0.56) were similar to ours. Our j values for flexion and extension were higher than the ones found by Viikari-Juntura (0.43 for flexion and 0.56 for extension).11 The authors explained their low j value to be related to the poor standardization of the tests. We applied standardized test and judging methods. Another difference with the study of Viikari-Juntura was the use of 3, rather than 2, answer categories. A study with similar methods, including measurement of range of movement of the cervical spine, was done by Pool et al.12 This study showed poorer j values compared to ours, but their way of assessing active or passive range of movement differed from ours. The recent systematic review of van Trijffel et al2 found that 9 studies examined reproducibility for the cervical spine. Just 1 study was of sufficient methodological quality showing fair to moderate reproducibility on stiffness. Overall, the reproducibility was slight to fair. The methodological quality of the current study is sufficient, showing reasonable reproducibility. A basic requirement for evaluating reproducibility is stable conditions of the participants between the first and the second physical examination. There was discussion between the examiners and participants after the physical examination. This revealed that probably the conditions during the first and second examination were not always equal. Some patients told the examiners that the mobility of the neck increased between the first and second examination, which might have resulted in less restricted movements during the second examination. Some other patients told them the pain
Journal of Manipulative and Physiological Therapeutics June 2006
in the neck increased during the examination, which might have resulted in more restricted movement during the second examination. Also, differences in interpretation could have influenced the reproducibility. Standardized testing and judging methods were used in the physical examination, but the judgment part allows room for slight differences in interpretation. Winkel et al6 classified rotation or lateral flexion as restricted if there was a difference in the range of motion between left and right. Normative values of the range of motion were not taken into consideration. The examiners, however, used also an implicit method considering sex, age, and race of the patient to determine whether a movement was restricted or not.6,7 Even when there was no difference between left and right, but the range of motion was small, the examiners considered the movement to be restricted. There appears to be no difference in the prevalence of positive findings between the 2 groups of patients with neck pain. Knowledge of history appeared to have no influence on the prevalence of positive findings. The study of Bertilson et al3, however, showed an increase of positive findings when the examiners know a patient’s history before the physical examination took place. Bertilson et al assigned this increase to examiner bias. Overall, assessments of mobility in daily practice are poorly reproducible; therefore, to apply treatment based only on the outcome of such an assessment is not recommended. In daily practice, treatment is applied based on history taking often in combination with findings of mobility assessment. Because of the moderate reproducibility of results, mobility assessment should be interpreted with caution when making clinical decisions.
CONCLUSION This study shows a reasonable reproducibility, when performed by nearly graduated physiotherapists, of the test for the assessment of active and passive range of motion of the neck. It also shows that knowledge of the patients’ history does not influence the reproducibility of range of motion assessment of the neck when performed by physiotherapy students.
Practical Applications ! The reproducibility for active and passive range of motion is moderate; thus, treatment should be based upon using range of motion information in combination with other information and findings. ! Assessment of neck extension showed good reproducibility. ! Knowledge of patients’ history had no influence on the reproducibility and prevalence of positive findings in this study.
Journal of Manipulative and Physiological Therapeutics Volume 29, Number 5
ACKNOWLEDGMENT There were no sources of funding for this study and the authors claim no conflicts of interest.
REFERENCES 1. Picavet HSJ, Schouten JSAG. Musculoskeletal pain in the Netherlands: prevalences, consequences and risk groups, the DMC3-study. Pain 2003;102:167-78. 2. van Trijffel E, Anderegg Q, Bossuyt PMM, Lucas C. Interexaminer reliability of passive assessment of intervertebral motion in the cervical and lumbar spine: a systematic review. Man Ther 2005;10:256-69. 3. Bertilson BC, Grunnesjf M, Strender LE. Reliability of clinical tests in the assessment of patients with neck/shoulder problems—impact of history. Spine 2003;2:2222-31. 4. Hoving JL, O’Leary EF, Niere KR, Green S, Buchbinder R. Validity of the neck disability index, Northwick Park neck pain questionnaire, and problem elicitation technique for measuring
Hoppenbrouwers et al Reproducibility of Range of Motion
disability associated with whiplash-associated disorders. Pain 2003;102:273-81. 5. Vernon H, Mior S. The neck disability index: a study of reliability and validity. J Manipulative Physiol Ther 1991;1: 409-15. 6. Winkel D, Aufdemkampe G, Meijer OG. Orthopedische geneeskunde en manuele therapie deel 4c wervelkolom. Eerste druk, Houten/Zavetem7 Bohn Stafleu van Loghum; 1991. 7. Chen J, Solinger AB, Poncet JF, Lantz CA. Meta analysis of normative cervical motion. Spine 1999;24:1571-8. 8. Dvorak J, Antinnes JA, Panjabi M, Loustalot D, Bonomo M. Age and gender related normal motion of cervical spine. Spine 1992;17:S394-8S394. 9. Cohen J. A coefficient of agreement for nominal scales. Educ Psychol Meas 1960;37-46. 10. Altman DG. Practical statistics for medical research. London7 Chapman and Hall; 1985. 11. Viikari-Juntura E. Interexaminer reliability of observations in physical examinations of the neck. Phys Ther 1987;67: 1526-32. 12. Pool JJ, Hoving JL, deVet HC, et al. The interexaminer reproducibility of physical examination of the cervical spine. J Manipulative Physiol Ther 2004;27:84-90.
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ABSTRACT Objective: The primary aim of this study was to assess the reproducibility of tests for the active and passive range of motion used in the physical examination for patients with neck pain. The secondary aim was to determine whether the history of the patients influences the reproducibility and the prevalence of positive findings. Methods: Sixty-nine participants were recruited in 3 physical therapy practices. Two examiners independently performed a physical examination on all participants. The examiners were blinded for patient characteristics (neck pain/no neck pain) and each other’s findings. History findings were available for only half the patients with neck pain. Cohen’s j was used to express reproducibility. Results: The reproducibility for active and passive range of motion was moderate (j = 0.52 and 0.54, respectively), but a wide range in j scores was found. Extension of the neck showed good reproducibility for both active and passive movements (j = 0.88 and 0.85), whereas lateral flexion showed poor reproducibility (j = 0.35 and 0.33). Knowledge of history had no influence on the reproducibility and prevalence of positive findings. Conclusion: The reproducibility for active and passive range of motion is moderate. Knowledge of the patient’s history did not influence the reproducibility and prevalence of positive findings. (J Manipulative Physiol Ther 2006;29:363-367) Key Indexing Terms: Reproducibility of Results; Cervical Vertebrae; Neck Pain; Range of Motion; Articular; Physiotherapy
N
eck pain is a common problem in The Netherlands with a prevalence of 20.6%.1 Approximately one third of these patients visit a physiotherapist for treatment. There is an increased interest in scientific studies concerning the effectiveness of physiotherapy. As a result, the need for reproducible methods of physical examination in patients with neck pain increases. There are just a few studies that evaluate the validity or reproducibility of physical examination procedures in patients with neck pain.2 For instance, Bertilson et al3 investigated the reliability of a range of clinical tests used in the examination of patients with neck pain and the influence of knowledge about patients’ medical histories on outcomes. In this study, the assessment of active and passive range of motion showed moderate reproducia
Hogeschool Rotterdam, Rotterdam, The Netherlands. Hogeschool Rotterdam, Rotterdam, The Netherlands. c Assistant Professor, Department of Physiotherapy, Hogeschool Rottterdam, Rotterdam, The Netherlands. d Epidemiologist and Senior Researcher at the Department of General Practice, Erasmus Medical Centre, University Rotterdam, The Netherlands. Submit requests for reprints to: Martine M.E.M. Eckhardt, PT, Rochussenstraat 728, 3015 ZG Rotterdam, The Netherlands (e-mail: [email protected]). Paper submitted June 3, 2005; in revised form November 11, 2005. 0161-4754/$32.00 Copyright D 2006 by National University of Health Sciences. doi:10.1016/j.jmpt.2006.04.007
bility with a j value of 0.29 for the examination without knowledge of the patient’s history and 0.27 with knowledge of the patient’s history. They concluded that knowledge of history did not affect the reliability of these tests. In physiotherapy, the selection of treatment is based on 2 sources, namely, history findings and physical examination. In physiotherapy, there are tests used, which have not been tested for reliability, or tests that are considered to be nonreliable. However, the conclusions based on the outcomes of these tests are used to make a treatment plan. The primary aim of this study was to assess the reproducibility of tests for active and passive range of motion used in the physical examination by a physiotherapist for patients with neck pain. The secondary aim was to determine whether the knowledge of the history of the patients influenced the reproducibility and prevalence of positive findings.
b
METHODS Design The current study is a test-retest design that took place between March 29, 2004, and May 7, 2004, in 2 physical therapy practices in Rotterdam and a health care center in Zwijndrecht, The Netherlands.
Study Population Patients asked to participate in this study were those who (1) had discomfort or pain localized in the cervical region 363
364
Hoppenbrouwers et al Reproducibility of Range of Motion
(C0-T4) with or without radiation to the shoulder or arm; (2) were between 18 and 65 years of age; and (3) who could read and understand the Dutch language. These patients were designated bneck pain patients.Q We also included people without neck pain as healthy subgroup. We excluded people with malignancies, fractures in the neck/shoulder region, congenital deformities of the cervical spine, patients with balance disorders, migraine, or patients who had undergone surgery in the cervical spine. All participants received a letter with information about the study, and then they gave oral and written consent to participate in the study. Procedures used were in accordance with the standards of the Medical Ethical Committee of the ErasmusMC, Erasmus Medical Center University.
Examiners The investigation was done by 2 physiotherapy students (MH and ME), who were in the last year of their study at Hogeschool Rotterdam, The Netherlands.
Procedure An independent physiotherapist of the participating practices arbitrarily clustered the neck pain patients into 1 of 2 groups. Group 1 included patients with neck pain of which the history was not revealed to the examiners, and group 2 included patients with neck pain whose history was known by the examiners before the physical examination. A third group included people without neck pain whose history was not revealed to the examiners. The independent physiotherapists received numbered envelopes, which included a letter with information about the study and the questionnaires. The envelopes for group 2 were marked with a cross. When the examiners received an envelope with a cross, they were able to look at the patient’s history before performing the physical examination. When they received an envelope without a cross, only the physical examination was carried out. The examiners were therefore blinded for the characteristics of people in groups 1 and 3.
Questionnaires Two questionnaires, an overall questionnaire and the Neck Disability Index (NDI), evaluated the history of the patients. The overall questionnaire consisted of 17 questions, developed by the examiners, that evaluated demographic data, the nature of the neck pain complaints, and some questions concerning the general health. The questionnaire mirrored the questions asked during a patient history normally carried out during the physiotherapeutic intake. The NDI consists of 10 questions to determine the disabilities a patient experiences in daily life due to neck pain. The NDI has appeared to be reliable and valid.4,5 All patients with neck pain filled in both questionnaires before the examination. The people without neck pain only filled in the demographic data and the questions about general health on the overall questionnaire.
Journal of Manipulative and Physiological Therapeutics June 2006
Physical Examination The physical examination consisted of 6 active and 6 passive movements to examine the range of movement of the cervical spine (C0-T4). These movements were flexion, extension, left and right rotation, and left and right lateral flexion. The tests were carried out and judged by a standardized procedure, as described by Dos Winkel who is a Dutch teacher in physical examination.6 For all assessment, the participants were in an active sitting position. For the active movements, the participants were instructed to make pure flexion, extension, rotation, and lateral flexion movements. For the passive movements, the examiners placed one hand on the head to guide the different movements and the other hand on the trunk for fixation. Every movement was carried out twice by each examiner and classified as normal or restricted. The second measurement was taken for the analysis; the first one was considered as a warming up movement. Flexion was considered restricted if the distance from the chin to the incisura jugularis was more than 2 cm. Extension was judged to be restricted if the plane line extending from the nose to the forehead did not reach the horizontal. Rotation and lateral flexion were judged by the difference between left and right. When one movement appeared to be more limited than the other this movement was defined as restricted. For rotation, the distance from the chin to the acromion was compared between left and right. The lateral flexion was judged by comparing the distance from the ear to the acromion at the left and the right side.6 In addition to these standardized judging methods, an implicit method, based on the examiners experience and considering sex, age, and race of the patient, was used to determine a normative value for the movements of rotation and lateral flexion.7,8 The 2 examiners performed pilot examinations on 15 fellow students to establish a similar examination procedure and criteria for the classification of the clinical findings. The examiners independently performed the physical examinations in a random sequence and did not inform the patients on the outcomes of the examination to prevent passing information to the second examiner.
Statistics Reproducibility was determined by calculation of Cohen’s j.9 A j value of 0.20 and smaller was considered to be poor, 0.21 to 0.40 to be moderate, 0.41 to 0.60 to be reasonable, 0.61 to 0.80 to be good, and higher than 0.81 to be very good.10 The prevalence of positive findings during the examination was also determined. The number of positive findings was defined as the sum of restricted movements found by the 2 examiners. The absolute number of positive findings was converted to a percentage per group.
Journal of Manipulative and Physiological Therapeutics Volume 29, Number 5
Hoppenbrouwers et al Reproducibility of Range of Motion
Table 1. Characteristics of the participants Group 1
Group 2
Table 3. Reproducibility per group Group
j active ROM4
j passive ROM4
Patients without neck pain Neck pain patients without history Neck pain patients with history
0.46 0.48 0.48
0.29 0.55 0.58
Group 3
Count Total Men/women
25 10/15
23 2/21
21 11/10
4 This j value is calculated including all movements.
Mean (SD) Age
43.0 (10.9)
Duration of complaints
Count
Acute (0-2 wk) Subacute (2 wk-3 mo) Chronic (N3 mo)
1
1
Group
2
2
22
20
Participation problems
Mean (SD)
NDI score (0-50)
11 (7.0)
17 (8.1)
1 Active Passive 2 Active Passive 3 Active Passive
Count4 4
1
14
7
5
11
1
3
0
1
No disability44 Mild disability Moderate disability Severe disability Complete disability Amount of pain
Mean (SD)
VAS score (0-100)
42.3 (23.3)
45.4 (11.3)
38.7 (11.7)
Table 4. Positive findings during testing Count of positive findings
Percent of positive findings
175 158
29.2 26.3
162 150
30.7 27.2
74 61
14.7 12.1
RESULTS Participants
42.0 (26.3)
4 In group 1 there is 1 missing value concerning the NDI score. 44 NDI classification by Vernon and Mior 5.
A total of 74 people were asked to participate in the current study. One person did not participate because of acquaintance with the examiners and another person was sick on the arranged examination date. Three people were excluded because of rheumatoid arthritis. Eventually, 69 people participated in this study; characteristics of the participants are shown in Table 1. The mean age of the participants was 42.5 years. Most patients with neck pain had chronic neck pain; only 6 people had acute or subacute neck pain. In group 2, most participants had a moderate disability score, whereas in group 1, mild disability was most common.
Reproducibility Table 2. Reproducibility per movement (n = 69) j active and passive ROM
Movement
j active ROM
j passive ROM
Flexion Extension Rotation (left/right) Lateral flexion (left/right)
0.57 0.88 0.49 (L: 0.43/R: 0.54) 0.35 (L: 0.33/R: 0.36)
0.77 0.85 0.51 (L: 0.47/R: 0.54) 0.33 (L: 0.23/R: 0.43)
0.65 0.87 0.50
All movements together
0.52
0.54
0.53
0.33
The j values for reproducibility are shown in Tables 2 and 3. The percentage of agreement for all active and passive range of motions between the 2 examiners was 78.2%. The reproducibility for active and passive range of motion was moderate (j = 0.53). We found a wide range in j values between the different movements. Extension showed good reproducibility for both the active and passive movements, whereas lateral flexion showed poor reproducibility for the active and passive movements. Overall, the reproducibility for the active and passive movements was similar, except for flexion; here the j value for the active movement showed a considerably lower value than the one for passive movement. This study showed no distinct influence of knowledge of the subjects’ histories on the reproducibility.
365
366
Hoppenbrouwers et al Reproducibility of Range of Motion
Positive Findings We determined the percentage of positive findings for all examined groups (Table 4). There was no apparent difference in the percentage of positive findings between neck pain patients based upon the examiners possessing knowledge of the participants’ histories (groups 1 and 2). In 12% to 15% of the tests on subjects without neck pain, a restricted movement of the neck was found.
DISCUSSION The overall active and passive examination of the neck had a reasonable reproducibility, with a j value of 0.53. There was no difference in the reproducibility or positive findings between the groups, with or without knowledge of patients’ histories. Our results were not comparable with earlier studies. A study carried out by Bertilson et al3 showed only a moderate reproducibility for active range of motion, whereas we found a reasonable reproducibility. The current study shows, however, that knowledge of a patient’s history has no influence on the reproducibility; this is similar to Bertilson et al.3 In a study carried out by Viikira-Juntura.11 the reproducibility was determined for the different movements of the examination of the active range of movement. Their j values for left and right rotation (0.40 and 0.56) were similar to ours. Our j values for flexion and extension were higher than the ones found by Viikari-Juntura (0.43 for flexion and 0.56 for extension).11 The authors explained their low j value to be related to the poor standardization of the tests. We applied standardized test and judging methods. Another difference with the study of Viikari-Juntura was the use of 3, rather than 2, answer categories. A study with similar methods, including measurement of range of movement of the cervical spine, was done by Pool et al.12 This study showed poorer j values compared to ours, but their way of assessing active or passive range of movement differed from ours. The recent systematic review of van Trijffel et al2 found that 9 studies examined reproducibility for the cervical spine. Just 1 study was of sufficient methodological quality showing fair to moderate reproducibility on stiffness. Overall, the reproducibility was slight to fair. The methodological quality of the current study is sufficient, showing reasonable reproducibility. A basic requirement for evaluating reproducibility is stable conditions of the participants between the first and the second physical examination. There was discussion between the examiners and participants after the physical examination. This revealed that probably the conditions during the first and second examination were not always equal. Some patients told the examiners that the mobility of the neck increased between the first and second examination, which might have resulted in less restricted movements during the second examination. Some other patients told them the pain
Journal of Manipulative and Physiological Therapeutics June 2006
in the neck increased during the examination, which might have resulted in more restricted movement during the second examination. Also, differences in interpretation could have influenced the reproducibility. Standardized testing and judging methods were used in the physical examination, but the judgment part allows room for slight differences in interpretation. Winkel et al6 classified rotation or lateral flexion as restricted if there was a difference in the range of motion between left and right. Normative values of the range of motion were not taken into consideration. The examiners, however, used also an implicit method considering sex, age, and race of the patient to determine whether a movement was restricted or not.6,7 Even when there was no difference between left and right, but the range of motion was small, the examiners considered the movement to be restricted. There appears to be no difference in the prevalence of positive findings between the 2 groups of patients with neck pain. Knowledge of history appeared to have no influence on the prevalence of positive findings. The study of Bertilson et al3, however, showed an increase of positive findings when the examiners know a patient’s history before the physical examination took place. Bertilson et al assigned this increase to examiner bias. Overall, assessments of mobility in daily practice are poorly reproducible; therefore, to apply treatment based only on the outcome of such an assessment is not recommended. In daily practice, treatment is applied based on history taking often in combination with findings of mobility assessment. Because of the moderate reproducibility of results, mobility assessment should be interpreted with caution when making clinical decisions.
CONCLUSION This study shows a reasonable reproducibility, when performed by nearly graduated physiotherapists, of the test for the assessment of active and passive range of motion of the neck. It also shows that knowledge of the patients’ history does not influence the reproducibility of range of motion assessment of the neck when performed by physiotherapy students.
Practical Applications ! The reproducibility for active and passive range of motion is moderate; thus, treatment should be based upon using range of motion information in combination with other information and findings. ! Assessment of neck extension showed good reproducibility. ! Knowledge of patients’ history had no influence on the reproducibility and prevalence of positive findings in this study.
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ACKNOWLEDGMENT There were no sources of funding for this study and the authors claim no conflicts of interest.
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