Original articleValidity of surface markers placement on the cervical spine for craniocervical posture assessment
Introduction
Evaluation of posture by using measurements on photographs (i.e. photogrammetry) has been increasingly used in research. The use of photogrammetry is considered more objective compared to the use of visual assessment that is subjective and therefore less sensitive (Gadotti and Biasotto-Gonzalez, 2010) and photogrammetry is cheaper and safer when compared to the use of radiographs (Chen and Lee, 1997).
The most commonly reported angle used in studies that investigate the craniocervical posture using photogrammetry is the craniovertebral angle (CVA) (Hackney et al., 1993; Watson and Trott, 1993; Lee et al., 1995; Johnson, 1998; Visscher et al., 2002; Gadotti and Magee, 2008; Armijo-Olivo et al., 2011). This angle refers to the degree of forward head posture, and is defined as the angle between the true horizontal through the spinous process of C7, with a line connecting the spinous process of C7 with the tragus. This angle is considered by some to be the clinical standard for measuring sagittal craniocervical posture (Hackney et al., 1993; Watson and Trott, 1993; Lee et al., 1995; Johnson, 1998; Visscher et al., 2002). The cervical inclination and cervical lordosis can also be measured using superficial measurements (Refshauge et al., 1994; Gadotti and Magee, 2008). The inclination angle was determined by a line connecting the spinous process of C2 and C7 with a horizontal line, and the cervical angle was derived from a line connecting C2 and C4, with a line connecting C4 and C7. Fig. 1 show the angles used to measure craniocervical posture using photogrammetry.
Manual palpation is required in order to identify the bony references for the surface marker placement and consequently to measure the angles. The reliability of the postural measurements depends on the ability of the clinician to correctly identify the reference points. If the reference marker is incorrectly placed, not only may intra-rater reliability be affected when performing repeated measurements, but also the measurements of posture reproducibility (intra-subject reliability) and validity. Although the ability to palpate a spinous process is considered to be a basic skill for manual therapy techniques, palpation procedures may fail. According to Robinson et al. (2009) few studies have investigated the validity of locating cervical spine spinous process by palpation compared to the gold standard for identification of spinal levels (radiographs).
The objective of this study was to determine the validity of placing reference markers on the cervical spine by manual palpation by comparing the results to radiographs. The reference points used to determine the angles commonly used to evaluate sagittal craniocervical posture will be tested.
Section snippets
Subjects
A total of 39 healthy female subjects (age mean = 33 ± 8.03 years old and body mass index = 22.7 ± 2.6) participated. They included subjects presenting with a normal craniocervical region defined as normal range of motion and absence of pain as evaluated by a physical therapist. Subjects were excluded if they presented with frequent pain in the craniocervical region, had a history of surgery or trauma to the head/neck, systemic disorder, and/or body mass index (BMI) greater than 30. This study
Results
From the first 22 subjects, 44 radiographs (2 radiographs from each subject) were analyzed which represents 176 surface markers placements (44 multiplied by 4 placements on each subject – C2, C4, C6, and C7). Of these 176 placements, 22 were misplaced (12.5%). Of the 12.5% of error, 1.7% (3) occurred attempting to find C2; 4.5% (8) for C4; 3.4% (6) for C6; and 2.8% (5) for C7. The misplaced surface markers were placed in between spinous processes or on the spinous process above or below the
Discussion
This study evaluated the validity of a physical therapist to place reference markers on the skin over spinous process of C2, C4, C6, and C7 by evaluating the markers positioning using radiographs (gold standard). As showed in Fig. 2, the direction of palpation was not the same for all spinous processes. Because of the natural curve of the cervicothoracic junction, the palpation of C6 and C7 was more caudal.
The ability to palpate spinous process is considered to be a basic skill for manual
Conclusions
The validity of markers placement on the cervical spine spinous processes was found to have good agreement based on one examiner. The least errors found were associated with the attempt to find C2 spinous process. Surprisingly, the markers placed on spinous process of C7 presented with the most errors when all the subjects were included. More studies should investigate the validity of markers placement on the cervical spine and include more raters with different levels of experience so the
Acknowledgments
This study was supported by the Alun Morgan Memorial Orthopaedic Physiotherapy from the Physiotherapy Foundation of Canada and Alberta Provincial CIHR Strategic Training Program in Bone and Joint Health. We would like to thank Jan Dubeta and the Glen Sather Clinic at the University of Alberta for the help in taking the radiographs.
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