Original articleReliability of manual examination and frequency of symptomatic cervical motion segment dysfunction in cervicogenic headache
Introduction
Cervicogenic headache (CGH) is a sub-group of secondary headache arising from cervical spine musculoskeletal dysfunction (Classification Committee of the International Headache Society, 2004). Classification of CGH is based on a range of subjective features and physical examination findings, which have been previously described (Sjaastad et al., 1998, Classification Committee of the International Headache Society, 2004). Recently it has been shown that the combination of three tests of cervical spine musculoskeletal function can identify subjects with CGH, from other headache forms, with 100% sensitivity and 94% specificity (Jull et al., 2007). These tests include cervical range of motion, manual examination of the upper cervical spine, and cervical motor control evaluated by the craniocervical flexion test.
One of the defining characteristics of CGH is the presence of cervical joint dysfunction. Dysfunction may involve any of the upper three cervical segments (Zito et al., 2006, Bogduk and Govind, 2009) and can be measured by manual examination (Maitland et al., 2001). Manual examination is a means of determining from which spinal segment pain arises, and consists of tests of unilateral passive accessory intervertebral motion (PAIM) and passive physiological intervertebral motion (PPIM). This information is important as it focuses the examination on a particular area of the cervical spine and also directs treatment.
Manual examination has high sensitivity and specificity to detect the presence or absence of cervical joint dysfunction in neck pain and headache patients (Jull et al., 1988, Jull et al., 1997, Sandmark and Nisell, 1995). However, these tests involve a high degree of skill on the part of the therapist, and their reliability has been questioned (Seffinger et al., 2004). The apparent inconsistency between sensitivity, specificity and reliability may be a reflection of poor research methods rather than manual examination being an unreliable procedure (Stochkendahl et al., 2006).
The cervical flexion–rotation test is gaining credibility as a useful aid in the classification of CGH (Hall et al., 2008a, Hall et al., 2008b). A positive test is purported to indicate dysfunction at the C1/2 motion segment (Stratton and Bryan, 1994). Although there is no direct research evidence to support this assumption, there is evidence from a number of studies that the flexion–rotation test is positive in subjects with C1/2 segmental dysfunction identified by manual examination (Hall and Robinson, 2004, Ogince et al., 2007, Hall et al., 2008a, Hall et al., 2008b). The importance of the flexion–rotation test in CGH evaluation and management is dependent on how commonly the C1/2 segment is the primary cause of the patient’s symptoms. To date, no study has intentionally sought to identify how frequently the individual segments from C0/1 to C3/4 are the dominant cause of CGH or whether multiple segments are involved.
Previously it has been documented that the C1/2 segment was the most symptomatic cervical motion segment in 80% of a sample of 28 subjects with CGH (Hall and Robinson, 2004). Similarly Zito et al. (2006) examined 27 subjects with CGH and reported that C1/2 segmental dysfunction was an important factor in headache diagnosis. In both studies determination of C1/2 segmental dysfunction relied on manual examination. A larger, more heterogenous sample is required, to further investigate these reports.
Knowledge of the frequency that each cervical motion segment is the predominant source of pain in CGH is important as it informs management. This information also informs the importance of procedures such as the flexion–rotation test. The purpose of this study was to investigate the reliability of manual examination procedures and the frequency that each or multiple segments above the C4 vertebra were the dominant source of pain. The hypotheses were that manual examination is reliable and that the C1/2 segment is most commonly the dominant symptomatic motion segment in subjects with CGH.
Section snippets
Methods
A cross-sectional study design was used to investigate the reliability of manual examination and the frequency that cervical motion segments above the C4 vertebra were the predominant source of symptoms in CGH. The Curtin University Human Research Ethics Committee granted approval for this study. Subjects gave written informed consent prior to the study commencement and were able to withdraw from the study at any time.
Results
Within the CGH group, considering all segments above C4, Examiner 1 and Examiner 2 found 51 and 55 of 60 subjects respectively had at least one symptomatic segment (Table 1). The unadjusted Kappa coefficient for inter-rater reliability was 0.68. When determining whether a single segment was positive or negative unadjusted kappa coefficients ranged from 0.61 to 0.71 (Table 1). The bias index was low for all segments but the prevalence index was ≥0.5 for C0/1 and C3/4 increasing the likelihood of
Discussion
This is the first reported study to identify by manual examination the frequency with which motion segments in the upper cervical region are the dominant symptomatic cervical segment in subjects with CGH. The C1/2 segment was identified as the dominant source of symptoms in 63% of cases where examiners agreed on manual examination. Other segments were less frequently dominant, with 30% of cases at C2/3, seven percent at C0/1 and none at C3/4. These results concured with previous reports that
Conclusions
Manual examination of the cervical spine was found to be reliable in 60 subjects with CGH. Examiners’ rating of manual examination identified the C1/2 segment as the most common symptomatic segment, with 63% of cases positive at this segment. The high frequency of C1/2 segmental involvement in CGH highlights the importance of examination and treatment procedures for this motion segment.
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2017, Musculoskeletal Science and PracticeCitation Excerpt :Further, when perceptions of movement are combined with pain responses and results from pain provocation tests, reliability and validity improves. For example, when this combination of assessments was used to identify “segmental dysfunction” in people with cervicogenic headache and, analysed with more appropriate statistical analysis (Sim and Wright, 2005), intra- and inter-observer reliability of manual examination was found to be good (Hall et al., 2010). In addition, using this combined assessment clinicians have been shown to reliably identify a motion segment that when subjected to local anaesthetic block significantly reduces a person's pain (an arguable gold-standard test for determination of a “source” of peripheral nociception) (Jull et al., 1988; Phillips and Twomey, 1996; Schneider et al., 2013).
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2016, Manual TherapyCitation Excerpt :However, these findings are not in agreement with previous reports (Armijo-Olivo et al., 2006; von Piekartz and Hall, 2013; Grondin et al., 2015). A previous study has demonstrated the high sensitivity and specificity of the FRT in detecting upper cervical movement impairment in patients with CGH (Hall et al., 2010). The current study failed to find a difference in upper cervical rotation between groups.