title: Identifiers suggestive of clinical cervical spine instability: a Delphi study of physical therapists.
abstract: OBJECTIVE
  Clinical cervical spine instability (CCSI) is controversial and difficult to diagnose. Within the literature, no clinical or diagnostic tests that yield valid and reliable results have been described to differentially diagnose this condition. The purpose of this study was to attempt to obtain consensus on symptoms and physical examination findings that are associated with CCSI.
  
  
  METHODS
  One hundred seventy-two physical therapists who were Orthopaedic Certified Specialists (OCS) or Fellows of the American Academy of Orthopaedic Manual Physical Therapists (FAAOMPT) participated in the survey.
  
  
  METHODS
  This study was a 3-round Delphi survey designed to obtain consensual symptoms and physical examination findings for CCSI.
  
  
  RESULTS
  The symptoms that reached the highest consensus among respondents were "intolerance to prolonged static postures," "fatigue and inability to hold head up," "better with external support, including hands or collar," "frequent need for self-manipulation," "feeling of instability, shaking, or lack of control," "frequent episodes of acute attacks," and "sharp pain, possibly with sudden movements." The physical examination findings related to cervical instability that reached the highest consensus among respondents included "poor coordination/neuromuscular control, including poor recruitment and dissociation of cervical segments with movement," "abnormal joint play," "motion that is not smooth throughout range (of motion), including segmental hinging, pivoting, or fulcruming," and "aberrant movement."
  
  
  CONCLUSIONS
  The Delphi method is useful in situations where clinical judgments are encountered but empirical evidence to provide evidence-based decision making does not exist. Findings of this study may provide beneficial clinical information, specifically when the identifiers are clustered together, because no set of clinical examination and symptom standards for CCSI currently exists. Diagnosis of CCSI is challenging; therefore, appropriate clinical reasoning is required for distinctive physical therapy assessment using pertinent symptoms and physical examination findings.
authors.affiliation: Duke University Medical Center 3907, Durham, NC 27710, USA. chad.cook@duke.edu
authors.forename: Chad
authors.initials: C
authors.lastname: Cook
authors.forename: Jean-Michel
authors.initials: JM
authors.lastname: Brismée
authors.forename: Robert
authors.initials: R
authors.lastname: Fleming
authors.forename: Phillip S
authors.initials: PS
authors.lastname: Sizer
mesh_terms: D000328:Adult; D002574:Cervical Vertebrae / Q000503:physiopathology*; D003697:Delphi Technique; D003937:Diagnosis, Differential; D005260:Female; D006801:Humans; D007593:Joint Instability / Q000175:diagnosis* / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D010808:Physical Examination; D026761:Physical Therapy Specialty; D014481:United States