Reliability of Cervical Movement Control Dysfunction Tests

[Michael McMurray]

Here is the first discussion board post for the 2015-2016 Residency year courtesy of Nick:

Inter- and intra-tester reliability of a battery of cervical movement control dysfunction tests.

http://www.manualtherapyjournal.com/article/S1356-689X(15)00009-0/abstract

Here is an article published in the most recent edition of Manual Therapy that I found to be highly relevant and clinically applicable. It corresponds to the upcoming course series (i.e., cervical spine), and also has Gwendolen Jull as one of its authors, a prolific researcher on the cervical spine.

A few aspects I found noteworthy:

– Only two physical therapists were used in assessing the patients motor control performance, a novice and an expert. Additionally, the novice was personally trained for 3 hours by the expert. I think that this must be taken into account when interpreting the results. In my judgment, the reliability ratings would be much more encouraging had, say, 10 therapists participated.

– The control patients did not have any musculoskeletal condition in the upper quarter, however they were being currently treated in physical therapy for another musculoskeletal condition. Both of these are significant. It is certainly reasonable to think that proximal pain/dysfunction (e.g., subacromial impingement pain) would influence cervical spine movement patterns. Additionally, patients who have movement dysfunction in one area (e.g., low back pain) might be more predisposed to have the same in another (i.e., cervical spine).

– With the exception of 3 movements, the patients received up to 8 practice trials of the movement with feedback from a therapist. This seemed high and I wonder how the results would have differed if, for example, only one or two practice trials had been given. Certainly, the results indicate not only movement dysfunction, but an inability to quickly respond to motor learning training.

A few questions for thought:

– One of the two tests that had greater ability to discriminate between individuals with neck pain from those without was active cervical extension in 4-point kneeling, emphasizing mid and lower cervical spine extension with maintenance of the upper cervical spine in neutral. In another recently published article that the authors reference (Elsig et al, 2014), cervicothoracic extension with maintenance of suboccipital neutral in standing was determined to discriminate between individuals with and without neck pain. Thus, it certainly appears that the ability to selectively move into lower cervical extension while keeping the upper cervical spine neutral is important Other than the quadruped exercise used in this study, have you found any other ways to actively encourage lower cervical extension?

– Have you found any of these movement tests to be particularly useful in your experience? Are there other tests of cervical movement control you have found to be helpful?

– The evaluating PTs in this group were blinded to the patient’s condition and had no subjective information or history. Have you discovered certain subjective complaints that cue you to pay particularly close attention to cervical movement control?

[sewhitta]

Nice post Nick. To answer you last question, I recently assessed a friend complaining of anterior shoulder pain. She’s a swimmer and c/o pain reaching overhead at end range shoulder flexion. She demonstrated significant tenderness in her biceps tendon. I screened her C-spine and found she also had cervical tightness with rotation to the same side and stiffness in her lower cervical spine. Turns out she was super tight in her ipsilateral levator scap, weak in lower trap, limiting her scapular upward rotation causing her to impinge. She was also significantly hypomobile in the lower cervical and upper thoracic spine. Take home point is, even with localized shoulder pain it would be beneficial to pay closer attention to the lower cervical and upper thoracic spine, as I feel hypomobility in this region could adversely effect the mobility of the scapula, or vice versa

[Nick Law]

Great case example, Sean. In your case, the abnormal movement patterns/muscle dysfunctions in the cervical and thoracic spines contributed to this patients shoulder pain. I think it is equally likely (as you stated that the end), that this could work in the reverse as well – underlying and perhaps painless GH/scapular dysfunction contributing to altered and painful movement patterns in the C spine.

[ABengtsson]

I agree with Sean… great post!
I like the point you made about the non-neck pain subjects being treated for something else (non-upper quarter) at the time of the study. It would be interesting to know what kind of pathologies those subjects were treated for, or at least include anything that could affect the cervical spine (postural deficits etc.) in the exclusion criteria.
The authors specifically mention that they did not address postural deficits (i.e. thoracic kyphosis) prior to the movement testing, which I’d say is very important as the neck pain may only be the result from the weak link breaking down.

I think it would have been beneficial if they were more precise about what the source of neck pain was (perhaps by grouping subjects similar to the Fritz article) to distinguish between symptomatic vs. non-symptomatic cMCD.

Regarding your last question: I’d say especially aggravating/easing factors like being in specific positions and also duration of position vs. onset and severity of symptoms. Depending on what the pt says, considering those could be a good pointer as to what the underlying cause is (muscular endurance/strength/activation etc.).

Sean, have you checked her general thorax mobility? I worked with a swimmer who had similar issues to your case (shoulder pain resulting from poor scapulo-thoracic movement) and I ended up working on his rib cage mobility a lot as his sp facet joints didn’t show a lot of hypomobility. I read a book by Diane Lee on the subject and one of the things she talks about is thorax mobility vs thoracic spine mobility. Could be interesting to look into especially with altered breathing patterns in swimmers. Thorax mobility might also be interesting when looking at cervical pain, considering regional interdependence models.

[Laura Thornton]

Great article Nick. I think Sean’s example of the close relationship between shoulder and cervical/thoracic spine perfectly describes how important a thorough shoulder screening is for cervical spine, and vice versa. I agree with Alex, it would have been beneficial to know more information on the source of the pain symptoms of the patients instead of just chronic, non-specific neck pain.

To respond to some of your questions:
1. To emphasize lower cervical extension without upper cervical extension, I would prescribe movements that start from the upper-mid thoracic spine and have the upper cervical spine blocked or with active cervical retraction. For example, performing active thoracic extension exercises with prone over ball or prone over bench (hands behind neck with interlaced fingers to block cervical extension) or while supine on foam roll with head supported, performing theraband UE exercises to strengthen lower trap/rhomboid/lats.

What do you guys think of using prone cervical retraction as a relative lower cervical extension/upper cervical flexion movement? It’s certainly not getting as much extension range as the movement in the study, but might be enough in the beginning for gravity-resisted strengthening.

3. Some general subjective points that I would add would be any history of concussion/MVA, long history of working a desk job or sustained positions (thinking postural syndrome, upper crossed syndrome, etc), or complaint of worsening neck pain at the end of the day.

Just some general thoughts about the article:
– It’s hard to relate videotaping to an actual clinical evaluation, especially with only one viewing angle and no sound. There is weak applicability of this assessment method from one static position and from 2 meters away. How much do we spend this far away from patients in real life scenarios, without sound, without knowing response/provocation of symptoms, and without palpation?
– Practice for two of the tests were not allowed before taping due to developers advocating “spontaneous performance” for these tests. As AJ spoke about today, we want to watch this “spontaneous performance” of all active movement without feedback at our initial assessment. I’m curious to know if the results would change if all movements were spontaneously performed, instead of the 5-8 practice trials beforehand.

[omikutin]

It was great meeting everyone this past weekend.
Nick- thanks again for posting this article. In class we learned several ways to clear out the shoulder and multiple test clusters to rule in or rule out certain pathologies. I like how this article focused mainly on the principals of consistency through the skills of observation: inter/ intra reliability.

Questions:
1) Segarra et al. focuses on maintaining sub-occipital neutral positioning during cervical extension. Maybe they’re trying more to isolate cervical extension while at the same time observing upper cervical stability? Maybe we’re “unloading” the lower cervical spine by decreasing the force potentially that could be caused by vectors from a shearing force if the upper cervical spine was not in neutral? Who knows. All I know is that I want to learn how to collect observational data points. I’m still trying to keep an open mind and potentially learn how to make the best correlations through “maybe related” statements. Regardless, we’re looking encouraging lower cervical extension. This weekend we saw an exercise that emphasized stretching the lower cervical spine in sitting, this maybe a postural cue or it could turn into an exercises or both. In past rotations, I try to think of exercises that patients could do through out the day. Many people sit throughout the day, so why not work on exercises there. My cue would me to sit up straight, apply a superior-inferior force via shoulders, see where they break, find a “neutral spine” position and cue a neutral upper cervical position and “imagine a string tied to the back of your heard and it’s lifting you up towards the ceiling”. Some of my patients loved it (to my surprise). They reported feeling “lighter, stretching, etc”. I would encourage that motion and progress to a hip hinge first in cardinal planes and then multiple plans (maintaining a neutral spine with changes in moment arms). So far that works for some patients and quadruped is a great progression from there.

2/3) GUESSE WHAT! I used the occipital release technique (not manip) on a patient today and she LOVED it (making friends.. great).. I backed tracked today and I gathered some more subjective information. My first thought was “hypermobile, floppy neck, duh… stability (what a rookie mistake)”. Her pain presentation seemed somatic in nature and followed the C2/3 referral pattern. My focus on this severely irritated in multiple directions patient is to figure out what relieves symptoms and work from there. She was irritable on her R C2/C3 facet glide and I practiced my prone grade II PAs. I wanted to be ambitious but realized I had to take it easy. It’s interesting how she can complete cervical flexion/ ext/ SB/ rotation though a painful motion. My question was “where is she gaining this movement when she’s moderate/ severely hypomoble in her right C2/C3 and mod hypomoble C3/C4”? These are things that I’m trying to observe. I’m now not just checking cervical cardinal plan motions, but I’m looking at quadrants. I want to see her impairment and further isolate that motion. I gave her cervical binder exercises in supine so that she could learn how to control her neck without compensations of traps, levator, superficial muscles.

Further questions I ask myself:
How do I start making “maybe related” bold statements that draw a clearer picture? How do I continue to encourage movement through a hypomobile segment without further encouraging hypermobile segments? Why is a particular facet hypomoble and how do I further prevent that motion? How do I continue to build salience of exercises throughout the day without patients falling back into their habitual patterns?
I also agree with Laura about spontaneous movements. I try to see how a person first performs an exercises after a simple demonstrations, observe the movement and then provided the appropriate cue.

[Nick Law]

Lots of good discussion…thanks everyone for really putting in the effort to make a thoughtful and thorough response.

I think that you made a great point, Laura, in that video tape analysis is very different from face to face patient examination that is a dynamic process. Certainly, the examination of these several different motor controls tasks is in its early stage. Hopefully we will see a more clinically based study in the coming years.

I also like the mention of including the mid/upper thoracic spine in the exercise prescription. A patient is certainly going to have a tough time controlling/moving into lower cervical extension if they are hyper-flexed in the mid to upper thoracic spine.

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