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Research report
Abstract
Aims: The cranio-cervical exion test (CCFT) was developed to indirectly measure the strength of the deep cervical exor muscles.
This pragmatic study was designed to analyse the reliability and discriminative validity of the test as used by osteopaths in the
clinical setting.
Methods: Forty subjects were categorised into groups according to two dierent sets of criteria. Firstly they were divided into three
groups who had either current neck pain, a history of neck pain but no current pain, or no history of neck pain. Secondly they were
divided into three groups according to their level of neck disability, which was either no disability, mild disability, or moderate
disability. The intra-rater and inter-rater reliability of the CCFT was calculated. Four practitioners performed the CCFT on each of
the 40 subjects and CCFT scores were analysed in terms of pain intensity, pain history and neck disability.
Results: Intra-rater reliability (ICC) was 0.78 (95% CI 0.47, 0.92) for performance index (PI), and 0.78 (95% CI 0.47, 0.92) for
activation score (AS). Inter-rater reliability (ICC) was 0.54 (95% CI 0.36, 0.70) for PI, and 0.57 (95% CI 0.37, 0.72) for AS.
A signicant correlation was found between the intensity of current pain and PI (r Z 0.37, P Z 0.02), but not for AS (r Z 0.29,
P Z 0.16). No statistically signicant dierence in the CCFT score was found between groups for either pain history or neck
disability. This result is in contrast to previous studies.
Conclusion: The practitioners in this study demonstrated good inter-rater reliability and excellent intra-rater reliability when using
the CCFT. However, the discriminative validity of the CCFT was not demonstrated in this study as the CCFT failed to discriminate
between those with current neck pain, those with a history of neck pain but no current pain, and those without neck pain.
2005 Elsevier Ltd. All rights reserved.
Keywords: Osteopathy; Neck pain; Cervical spine dysfunction; Cranio-cervical exion test; Reliability; Validity
1. Introduction
At any point of time, approximately 10e15% of the
international population will be suering an episode
of neck pain, and 40% will suer neck pain during a
12-month period.1 One well designed, random population based study surveyed 812 people and reported that
18% of individuals woke with cervical pain and 4%
* Corresponding author.
E-mail address: sue.hudswell@optusnet.com.au (S. Hudswell).
1746-0689/$ - see front matter 2005 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijosm.2005.07.003
99
100
2.3. Instrumentation
101
102
Table 1
Reliability key (after Shrout and Fleiss21)
ICC O 0.75
ICC Z 0.4e0.75
ICC ! 0.4
Excellent reliability
Good reliability
Poor reliability
absolute agreement. For the inter-rater analysis a twoway random eects model was used whereby the targets
were judged as a random sample and the practitioners
were also judged as a random eect. Agreement was
dened in terms of absolute agreement whereby the
systematic dierences among levels of ratings are
considered relevant and rater variability contributes to
the denominator of the ICC estimates.22 See Table 1
for reliability key.
2.6.2. Associations between groups
Data were checked for adherence to a normal
distribution. The Shapiro Wilks test showed that only
the performance index scores were normally distributed.
Data were therefore analysed using nonparametric
Spearmans rank correlation coecients to determine
if any signicant correlation was present between the
following variables: pain intensity (VAS); neck disability
index scores; mean scores of all practitioners; scores of
each practitioner, 1e4; and duration of pain (in patients
with current pain). Correlational analysis was included
in this study to identify relationships between scores in
the CCFT and variables such as pain intensity and neck
disability scores which may not have been strong
enough to result in a statistically signicant dierence
between groups using one-way ANOVA, but could
show that, for example, those with higher VAS scores
had lower scores on the CCFT.
2.6.3. Dierences between groups
One-way ANOVA was used to test for dierences in
outcome of the CCFT (activation score and performance index) between those with (1) no history of pain,
a history of pain but no current pain, and those with
3. Results
Intra-rater reliability was assessed for one rater,
while inter-rater reliability was assessed for all four
raters used in the study. Excellent intra-rater reliability was demonstrated for both the performance index
(ICC Z 0.78; 95% CI 0.47, 0.92), and also for the
activation score (ICC Z 0.78; 95% CI 0.47, 0.92),
demonstrating the consistency of the test. Good interrater reliability was demonstrated for the performance
index (ICC Z 0.54; 95% CI 0.36, 0.70) and also for
activation score (ICC Z 0.57; 95% CI 0.37, 0.72),
demonstrating that the test has good concordance
between raters.
A strong positive correlation was found between
subject pain intensity (VAS) and neck disability index
scores (r Z 0.74, P Z 0.0001, 95% CI 0.56, 0.85),
meaning that those subjects who experienced higher
levels of pain also reported higher levels of disability.
Pain intensity scores were shown to have a negative
correlation with performance index (r Z 0.37,
P Z 0.02, 95% CI 0.07, 0.61). Therefore, those
subjects who experienced higher levels of pain had lower
scores on the CCFT. Signicant correlations were found
as detailed on the correlation matrixes for activation
score and performance index (refer Tables 2 and 3).
The participants history of neck pain on entry to the
study is summarised in Table 4. These groups were
compared with each other in terms of their performance
index and activation score.
Despite the signicant correlation between pain
intensity scores and CCFT scores, no signicant
dierence was demonstrated for mean activation score
(F2,37 Z 1.97; P Z 0.15) and performance index
Table 2
Correlation matrix for activation score
VAS
NDI
MPS
Practitioner 1
Practitioner 2
Practitioner 3
Practitioner 4
Pain duration
VAS
NDI
MPSAS
Practitioner 1
Practitioner 2
Practitioner 3
Practitioner 4
1
0.74**
0.29
0.24
0.29
0.32*
0.23
0.77**
1
0.24
0.15
0.33*
0.30
0.14
0.68**
1
0.74**
0.91**
0.87**
0.87**
0.22
1
0.61**
0.55**
0.56**
0.13
1
0.74**
0.70**
0.78**
1
0.72**
0.27
1
0.23
*Indicates correlation is statistically signicant at 0.05 level; **indicates correlation is statistically signicant at 0.001 level; VAS: score on visual
analogue scale where 0 Z no pain and 10 Z unbearable pain; NDI: score on Neck Disability Index Questionnaire; MPS: mean scores of all
practitioners; MPSAS: mean scores of all practitioner (activation Scores); Practitioners 1e4: individual scores of each practitioner; pain duration: if
subject has current pain, how long it has been present in months.
103
VAS
NDI
MPS
Practitioner 1
Practitioner 2
Practitioner 3
Practitioner 4
Pain duration
VAS
NDI
MPSPI
Practitioner 1
Practitioner 2
Practitioner 3
Practitioner 4
1
0.74**
0.37*
0.23
0.35*
0.40**
0.32*
0.77**
1
0.27
0.09
0.35*
0.32*
0.17
0.68**
1
0.74**
0.89**
0.79**
0.85**
0.23
1
0.57**
0.50**
0.59**
0.13
1
0.57**
0.74**
0.20
1
0.53**
0.34*
1
0.22
*Indicates correlation is statistically signicant at 0.05 level; **indicates correlation is statistically signicant at 0.001 level; VAS: score on visual
analogue scale where 0 Z no pain and 10 Z unbearable pain; NDI: score on Neck Disability Index Questionnaire; MPS: mean scores of all
practitioners; MPSPI: mean scores of all practitioners (performance index); Practitioners 1e4: individual scores of each practitioner; pain duration: if
subject has current pain, how long it has been present in months.
4. Discussion
The reliability of the CCFT as used in this study was
demonstrated to be good, and formed the basis for
testing the discriminative validity of the test. All
Table 4
Participant history of neck pain on entry to the study
History of neck pain
No history of neck pain
History of neck pain,
but no current pain
Current neck pain
Number (%)
7 (17.5)
8 (20)
25 (62.5)
Table 5
Participant neck disability on entry to the study
Neck disability score
Number (%)
No disability
Mild disability
Moderate disability
21 (52.5)
17 (42.5)
2 (0.05)
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5. Conclusion
This study sought to ascertain the usefulness of the
Clinical CCFT to osteopaths in the clinical setting. The
test was found to have excellent intra-rater, and good
inter-rater, reliability. In contrast to other studies, the
test was unable to dierentiate between subjects with
neck dysfunction and those without. Signicant correlations were, however, found between the intensity of
neck pain, the magnitude of neck disability, and scores
of the CCFT. The results of this study fail to conrm
that the Clinical CCFT can measure neck dysfunction in
clinical practice. It may be that the staged version of the
CCFT test would be a more useful tool.
Acknowledgements
We would like to thank our colleagues who provided
their time as raters.
Appendix 1.
Data collection sheet (with example) (rater number 1 and patient
number 1)
Hold
Hold
Hold
Hold
Hold
Hold
Hold
Hold
Hold
Hold
a
b
c
1
2
3
4
5
6
7
8
9
10
Activation
scorea
(mmHg)
Baseline
score
(mmHg)
Pressure
increaseb
(mmHg)
22
22
22
22
22
22
N/a
N/a
N/a
N/a
20
20
20
20
20
20
20
20
20
20
2
2
2
2
2
2
N/a
N/a
N/a
N/a
Completed
number
of holds: 6
Performance
indexc
2 ! 6 Z 12
References
1. Ariens G, Borghouts A, Koes B. Neck pain. In: Crombie I, editor.
Epidemiology of pain. Seattle: IASP Press; 1999. p. 23555.
2. Gordon S, Trott P, Grimmer K. Waking cervical pain and
stiness, headache, scapular or arm pain: gender and age eects.
Aust J Physiother 2002;48:915.
3. General Osteopathic Council. Snapshot survey 2001. Osteopath
2001;4:8.
4. Huskisson E. Visual analogue scales. In: Melzack R, editor. Pain
measurement and assessment. New York: Raven Press; 1983.
p. 337.
5. Vernon H, Mior S. The neck disability index: a study of reliability
and validity. J Manipulative Physiol Ther 1991;14:40915.
6. Jull G, Barrett C, Magee R, Ho P. Further clarication of the
muscle dysfunction in cervical headache. Cephalalgia 1999;19:
17985.
7. Jull G. Deep cervical exor muscle dysfunction in whiplash.
J Musculoskel Pain 2000;8:14354.
8. Jull G, Kristjansson E, DallAlba P. Impairment in the cervical
exors: a comparison of whiplash and insidious onset neck pain
patients. Man Ther 2004;9:8994.
9. Sterling M, Jull G, Vincenzino B, Kenardy J. Characterization of
acute whiplash-associated disorders. Spine 2004;29:1828.
10. Falla D, Jull G, Hodges P. Patients with neck pain demonstrate
reduced electromyographic activity of the deep cervical exor
muscles during performance of the craniocervical exion test.
Spine 2004;29:210814.
11. Falla D, Bilenkij G, Jull G. Patients with chronic neck pain
demonstrate altered patterns of muscle activation during performance of a functional upper limb task. Spine 2004;29:143640.
12. Cholewicki J, Panjabi M, Khachatryan A. Stabilizing function of
trunk exoreextensor muscles around a neutral spine position.
Spine 1997;22:220712.
13. Jull G. Physiotherapy management of neck pain of mechanical
origin. In: Giles L, Singer K, editors. Clinical anatomy and
management of cervical spine pain. Edinburgh: ButterworthHeinemann; 1998. p. 16891.
14. Falla D, Campbell C, Fagan A, Thompson D, Jull G. Relationship between cranio-cervical exion range of motion and pressure
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