Elsevier

Manual Therapy

Volume 15, Issue 6, December 2010, Pages 542-546
Manual Therapy

Original article
Reliability of manual examination and frequency of symptomatic cervical motion segment dysfunction in cervicogenic headache

https://doi.org/10.1016/j.math.2010.06.002Get rights and content

Abstract

This study investigated the reliability of manual examination procedures and the frequency that each or multiple segments in the upper cervical spine above the C4 vertebra were the dominant source of pain in subjects with cervicogenic headache (CGH). Eighty subjects were evaluated, 60 with CGH (39 females, mean age 33 years) and arbitrarily a further 20 asymptomatic subjects (13 females, mean age 34 years) included to reduce examiner bias, but subsequently omitted from data analysis. Two experienced physiotherapists examined on the same day each subject with standard manual examination procedures, independently rating each segment in the upper cervical spine above the C4 vertebra for involvement. Examiners were blind to each other’s findings and the subject’s clinical status. Standard and adjusted Kappa coefficients were calculated for each segment in symptomatic subjects only. Chi-squared analysis for goodness of fit was used to identify the segment that was most frequently determined the predominant symptomatic segment. Manual examination above the C4 vertebra showed good reliability. The C1/2 segment was most commonly symptomatic, with a positive finding at this segment in 63% of cases. The high frequency of C1/2 involvement in CGH highlights the importance of examination and treatment procedures for this motion segment.

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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