title: An investigation into the validity of cervical spine motion palpation using subjects with congenital block vertebrae as a 'gold standard'.
abstract: BACKGROUND
  Although the effectiveness of manipulative therapy for treating back and neck pain has been demonstrated, the validity of many of the procedures used to detect joint dysfunction has not been confirmed. Practitioners of manual medicine frequently employ motion palpation as a diagnostic tool, despite conflicting evidence regarding its utility and reliability. The introduction of various spinal models with artificially introduced 'fixations' as an attempt to introduce a 'gold standard' has met with frustration and frequent mechanical failure. Because direct comparison against a 'gold standard' allows the validity, specificity and sensitivity of a test to be calculated, the identification of a realistic 'gold standard' against which motion palpation can be evaluated is essential. The objective of this study was to introduce a new, realistic, 'gold standard', the congenital block vertebra (CBV) to assess the validity of motion palpation in detecting a true fixation.
  
  
  METHODS
  Twenty fourth year chiropractic students examined the cervical spines of three subjects with single level congenital block vertebrae, using two commonly employed motion palpation tests. The examiners, who were blinded to the presence of congenital block vertebrae, were asked to identify the most hypomobile segment(s). The congenital block segments included two subjects with fusion at the C2-3 level and one with fusion at C5-6. Exclusion criteria included subjects who were frankly symptomatic, had moderate or severe degenerative changes in their cervical spines, or displayed signs of cervical instability. Spinal levels were marked on the subject's skin overlying the facet joints from C1 to C7 bilaterally and the motion segments were then marked alphabetically with 'A' corresponding to C1-2.Kappa coefficients (K) were calculated to determine the validity of motion palpation to detect the congenitally fused segments as the 'most hypomobile' segments. Sensitivity and specificity of the diagnostic procedure were also calculated.
  
  
  RESULTS
  Kappa coefficients (K) showed substantial overall agreement for identification of the segment of greatest hypomobility (K = 0.65), with substantial (K = 0.76) and moderate (K = 0.46) agreement for hypomobility at C2-3 and C5-6 respectively. Sensitivity ranged from 55% at the C5-6 CBV to 78% at the C2-3 level. Specificity of the procedure was high (91 - 98%).
  
  
  CONCLUSIONS
  This study indicates that relatively inexperienced examiners are capable of correctly identifying inter-segmental fixations (CBV) in the cervical spine using 2 commonly employed motion palpation tests. The use of a 'gold standard' (CBV) in this study and the substantial agreement achieved lends support to the validity of motion palpation in detecting major spinal fixations in the cervical spine.
authors.affiliation: Canadian Memorial Chiropractic College, 1900 Bayview Avenue, Toronto, Ontario, Canada. khumphreys@cmcc.ca
authors.forename: Barry K
authors.initials: BK
authors.lastname: Humphreys
authors.forename: Marianne
authors.initials: M
authors.lastname: Delahaye
authors.forename: Cynthia K
authors.initials: CK
authors.lastname: Peterson
mesh_terms: D002574:Cervical Vertebrae / Q000002:abnormalities*; D002684:Chiropractic / Q000193:education; D006801:Humans; D007593:Joint Instability / Q000175:diagnosis*; D020393:Manipulation, Spinal; D009038:Motion; D015588:Observer Variation; D010173:Palpation / Q000592:standards*; D010808:Physical Examination; D015203:Reproducibility of Results; D013122:Spinal Diseases / Q000175:diagnosis*; D013334:Students; D021801:Zygapophyseal Joint