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International Journal of Osteopathic Medicine 8 (2005) 98e105

www.elsevier.com/locate/ijosm

Research report

The cranio-cervical exion test using pressure biofeedback: A


useful measure of cervical dysfunction in the clinical setting?
Sue Hudswell*, Michael von Mengersen, Nicholas Lucas
School of Exercise and Health Sciences, University of Western Sydney, Penrith South, NSW 1797, Australia
Received 26 May 2005; received in revised form 7 July 2005; accepted 12 July 2005

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

suered from it all day.2 Osteopaths have a large


proportion (37.3%) of their case load devoted to the
treatment of patients with neck problems.3 It is therefore
important to identify the reliability and clinical utility of
tests that are available to measure neck dysfunction.
Two validated outcome measures are used in this
paper as indicators that subjects suer from cervical
dysfunction. The operational denition of cervical
dysfunction as used in this study encompasses the
results of these two outcome measures. The rst is the
intensity of neck pain as self-reported by subjects on
a visual analogue scale (VAS)4 where zero represents no

S. Hudswell et al. / International Journal of Osteopathic Medicine 8 (2005) 98e105

pain, and 10 represents the worst imaginable pain. The


second measure is the subjects score on a Neck
Disability Index Questionnaire.5 The reliability and
discriminative validity of a third measure of cervical
dysfunction, the cranio-cervical exion test (CCFT), is
explored in this study.
Research into muscle dysfunction in subjects with
neck pain of varying aetiology has led to the discovery
of widespread impairment in the stabilising muscles of
the cervical spine.6e9 A signicant loss of strength in the
deep neck exor muscles has been found in subjects with
current or resolved neck pain as compared to those with
no neck pain. Falla et al.10 conducted a cross-sectional
study of 20 subjects in which they found that the
amplitude of electromyographic activity of the deep
neck exor muscles during performance of the CCFT, as
measured on the posterior oropharyngeal wall, was
signicantly less for subjects with neck pain than for
those without. Falla et al. additionally explored patterns
of activation in deep and supercial muscles of the neck.
They compared subjects with and without chronic neck
pain, and found altered patterns of activation where
those with neck pain demonstrated greater activation of
accessory neck muscles during a functional upper limb
task.11 In an earlier paper, Cholewicki et al.12 hypothesised that the presence of increased activation of the
sternocleidomastoid (SCM) muscle provides the inference that altered patterns of coordination may be
present between deep and supercial exor muscles in
patients with neck pain, and that this higher SCM
activity may be a compensation for poorer active
contractile capacity of longus colli and capitis muscles.12
Researchers at the University of Queensland (UQ)
developed the CCFT which uses a pressure biofeedback
unit to measure deep neck exor muscle strength.13
The CCFT was originally proposed by Jull et al.13 in
1998 as a method for indirect measurement of the
activation of the deep neck exors in order to direct
therapeutic exercise to those stabilising muscles where
strength decits were found. In an early version of the test
(1998) subjects were required to attempt to perform 10
repetitions of a 10-s hold of upper cervical exion in the
supine position, while the pressure generated between the
cervical spine and treatment bench was being monitored
by an inatable air lled pressure biofeedback unit. The
performance index of the CCFT is calculated by multiplying the pressure increase achieved from a baseline of
20 mmHg (dened as the activation score), and the
number of successful holds. Jull et al.6 found intra-rater
reliability for the test to be high (ICC Z 0.93 for
performance index; ICC Z 0.81 for increase of activation
score) in a study of patients with cervicogenic headache.
A pressure biofeedback unit and stopwatch are the only
equipment required for this test and thus it is well suited
to the osteopathic clinical environment. In this paper the
1998 test will be referred to as the Clinical CCFT.

99

A modied, staged version of the CCFT was


described in a study of deep neck exor dysfunction in
whiplash subjects.7 In this staged CCFT, the aim is for
the subject to perform upper cervical exion and raise
the pressure of the inatable cu over 5 repetitions,
from 20 mmHg to 30 mmHg in 2 mmHg increments.
For example, the rst target is to raise the pressure from
20 mmHg to 22 mmHg and hold for 5 s and then relax,
and the second target is to raise the pressure from
20 mmHg to 24 mmHg and hold for 5 s and then relax.
The ability to target and hold the position steady (as
analysed by computer assisted pressure recording), and
the activity in the supercial neck exors (using
electromyography) was measured during the test. While
this testing procedure is likely to be more accurate than
the Clinical CCFT described above, the equipment
required is not available in most osteopathic clinics. This
modied, staged version of the test will be referred to in
this paper as the Laboratory CCFT.
Recent studies have added to the weight of evidence
suggesting validity of the Laboratory CCFT as a test of
deep neck exor activity. Falla et al.14 used a digital
imaging method to demonstrate a linear relationship
between the incremental targets of the Laboratory
CCFT and the percentages of full range cranio-cervical
exion range of movement. In another study, Falla
et al.15 evaluated an EMG technique for direct measurement of deep neck exor action by placement of
electrodes over the posterior oropharyngeal wall. A linear
relationship was found between the amplitude of deep
neck exor muscle activity and incremental stages of the
Laboratory CCFT.
Other studies have shown decreased activation of deep
neck exors in patients with current or resolved neck
dysfunction in performance of the CCFT. This pattern
was found by Jull et al.6 who used the Clinical CCFT to
test 15 patients with cervicogenic headache and 15
controls.6 The Laboratory CCFT identied deep neck
exor weakness together with increased activation of
supercial neck exors in patients with neck pain of
insidious onset,7 and with neck pain following whiplash.7e9 All research studies have found that the CCFT
cannot dierentiate between dierent aetiologies of neck
pain but can dierentiate between patients who have neck
pain or dysfunction and those who do not. Nederhand
et al.16 and Jull et al. 8 failed to nd any correlation
between length of history of neck pain and scores in the
CCFT. Uhlig et al.17 found that deep neck exor
dysfunction was not pathology specic and suggested
that pain was probably the stimulus for this pattern of
muscle reaction. In a single case study, retraining the deep
neck exor muscles was reported to yield improvements in
cervicogenic headache symptoms18 and deep neck exor
retraining has also been reported to have a positive
eect on the symptoms of other neck conditions.19 A
randomised controlled trial of specic deep neck exor

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S. Hudswell et al. / International Journal of Osteopathic Medicine 8 (2005) 98e105

retraining exercise and cervical manipulative therapy in


200 subjects suering from cervicogenic headache found
signicant reduction in headache frequency and intensity
with both treatments but found that combined therapies
were not superior to either treatment alone.20 However,
while the CCFT group and combined CCFT and
manipulation group experienced improvements in deep
neck exor muscle strength over the period of the trial, the
manipulation only group did not.
While the Laboratory CCFT has been well studied,
the present study was designed to explore the ability of
the Clinical CCFT, as employed by novice testers, to
dierentiate patients with neck dysfunction from those
without, and thus investigate the usefulness and validity
of the test in the clinical setting. No attempt was made
to investigate whether performance of the Clinical
CCFT could dierentiate between varying aetiologies
of neck pain. In order to increase the internal validity of
this study, the intra-rater and inter-rater reliabilities of
the CCFT were also investigated.
If the Clinical CCFT is able to reliably measure neck
dysfunction in terms of perceived pain and disability, and
by inference, strength decits in the deep neck exor
muscles, it can point the way to therapeutic treatments
designed to improve motor control of the deep neck
exor and supercial cervical muscles. In clinical
practice, patients will be able to monitor their progress
by repeated application of the test, which will oer
feedback and therefore motivation to perform the
prescribed home exercise programme. The Clinical
CCFT may be a valuable tool for osteopaths in diagnosis
and treatment of cervical pain and dysfunction.

spine. In order to test the discriminative validity of the


CCFT, both symptomatic and non-symptomatic subjects
are required. Therefore, subjects with current neck pain
or resolved neck pain, and a history of neck pain of
insidious onset, or neck pain after whiplash grades 1 and
2, were included, as were participants without a current
or pre-existing history of neck pain. Approval for the
study was granted by the Human Research Ethics
Committee of the University of Western Sydney.
2.2. Design
2.2.1. Part 1: intra-rater and inter-rater reliability
study
A between-days repeated measures intra-rater reliability study was undertaken on 15 of the 40 participants. A single day repeated measures inter-rater
reliability study was performed on 40 participants using
four testers.
2.2.2. Part 2: associations between groups
A correlational study tested for linear relationships
between intensity and duration of present pain; score on
the neck disability index; activation score; and performance index of the CCFT.

2. Materials and methods

2.2.3. Part 3: dierences between groups


A blinded comparative study was undertaken to
identify: (1) if there were any dierences in the
performance in the CCFT between participants with
current neck pain, a history of neck pain, but no current
pain, and no history of neck pain; and (2) if there were
any dierences in performance of the CCFT between
groups with no neck disability, mild neck disability and
moderate neck disability.

2.1. Participant recruitment

2.3. Instrumentation

A convenience sample of 40 subjects (22 female, 18 male;


mean age 24.7; age range 18e40) was recruited from
students at the University of Western Sydney (UWS),
together with members of the public who answered an
advertisement in the UWS UNICLINIC (a university
based outpatient clinic providing osteopathy services).
From the 40 participants, a random sample of 15
was selected for participation in the intra-examiner
reliability study (9 female, 6 male; mean age 23.6; age
range 18e30).
Volunteers were excluded from the study if they had
a history of: whiplash and associated disorder (WAD)
grades 3 and 4; fracture; tumour; or arthritis of the
cervical spine. Subjects were also excluded if they suered
from any neurological, systemic or inammatory disease.
Participants were included if they were within the age
range of 18e40 in order to minimise the risk of agerelated degenerative changes being present in the cervical

Four inatable pressure biofeedback units (Stabilizer,


Chattanooga South Pacic) (Fig. 1) were calibrated with
weights to check that they showed the same linear
relationship between applied loads and pressure changes
in the ranges used in this study. The pressure biofeedback unit is reported to have a tolerance of
G3 mmHg of pressure (Enmore Medical Specication
Sheet, 2002).
2.4. Procedure
2.4.1. Training session
Participants received written and verbal information
about the test procedures. Correct procedure for the
action required in the CCFT was taught in a 1-h session.
The testing action is a pure head nod while in the supine
position, and requires both care and precision for correct
performance. Patients with poor activation capabilities

S. Hudswell et al. / International Journal of Osteopathic Medicine 8 (2005) 98e105

Fig. 1. Pressure biofeedback unit (Stabilizer, Chattanooga South


Pacic).

of their deep neck exors may use substitution strategies


to achieve contraction. Common substitutions include
recruitment of supercial exors, sternocleidomastoid
and scalenes, and even the hyoids and platysma. Alternatively, the patient may perform an incorrect chin
retraction action or may try to compensate for poor tonic
function by performing the action too quickly.13
2.5. Testing procedure
One week after the initial training session all subjects
signed an informed consent statement. Each subject
completed a short questionnaire screening for the
existence and degree of current pain, or resolved pain.
The intensity of current pain was self-reported using
a visual analogue scale (VAS) where 0 Z no pain and
10 Z unbearable pain. Subjects also completed a Neck
Disability Index Questionnaire. Raters were blinded to
the results of these instruments as they were only
handled by the authors and the results not disclosed to
the raters. Raters were randomly assigned a number
from 1 to 4. To limit order bias, subjects were randomly
divided into groups of four and randomly assigned
a combination of the numbers 1e4 (1, 2, 3, 4 or 3, 1, 4, 2
or 2, 4, 1, 3 or 4, 3, 2, 1) that corresponded to the order
in which they were examined by the four raters.
Four novice raters were trained by the authors in a 1-h
session which took place one week before the test was
administered. The practitioners practiced with the
instrument over the week before testing. On the day of
the test each of the four raters administered the CCFT
to each patient. A break of 2 min was allowed between
each test to minimise fatigue. The temperature of the
room was kept stable for the duration of the study, and

101

all four treatment tables were identical. Refer to Fig. 2


for patients position.
The patient lay in the supine crook position, with the
head supported on folded towels so that the neck
continued the horizontal line of the body. The Stabilizer
pressure biofeedback unit was placed under the suboccipital region and inated to a pressure of 20 mmHg
in order to ll the space of the cervical lordosis. Subjects
were required to attempt 10 ! 10-s holds of the upper
cervical exion action. A rest period of 10 s was allowed
between holds. The maximum pressure above baseline,
that was achieved and held in a steady manner for 10 s,
is dened as the activation score. A performance index
was calculated by multiplying the pressure increase
(from the baseline of 20 mmHg) by the number of
successfully completed 10-s holds. Loss of pressure of
greater than 2 mmHg of the target was regarded as
failure and the number of repetitions to that point was
used in the calculation of holding capacity.13 (Refer
Appendix 1.) Subjects were advised to discontinue the
test if pain was experienced.
Fifteen participants were randomly selected to attend
for a second session the following week. Those subjects
were requested to refrain from actively exercising the
deep neck exor muscles until retesting. After one week,
only one rater (practitioner 3), retested 15 participants
using the same protocol as before.

2.6. Data analysis


2.6.1. Part 1: intra-rater and inter-rater reliability
study
An intra-class correlation coecient (ICC) was
calculated for the overall reliability of the CCFT (based
on the performance index) as well as a sub-analysis of
the activation score.21 For the intra-rater analysis a oneway random eects model was used whereby only the
targets were judged as a random eect, with measures of

Fig. 2. Subject and practitioner positioning as employed in the study


(see text for further description).

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S. Hudswell et al. / International Journal of Osteopathic Medicine 8 (2005) 98e105

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

current pain; and (2) those with no neck disability, mild


neck disability and moderate neck disability.
All data were analysed using SPSS for Windows
Version 13, with statistical signicance set at a Z 0.05.

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.

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S. Hudswell et al. / International Journal of Osteopathic Medicine 8 (2005) 98e105


Table 3
Correlation matrix for performance index

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.

(F2,37 Z 3.09; P Z 0.057) between (1) those who had no


history of neck pain; (2) those who had a history of neck
pain, but did not have current pain; and (3) those who
had current pain.
The participants history of neck disability on entry
to the study is summarised in Table 5. These groups
were compared with each other with regard to performance index and activation score.
There was no signicant dierence in mean activation
score (F2,37 Z 2.65; P Z 0.084), and performance index
(F2,37 Z 2.87; P Z 0.070) between (1) those with no neck
disability; (2) those with mild disability; and (3) those
with moderate disability.
Due to the unexpected nding that no signicant
dierence was demonstrated between CCFT scores of
three dierent groups based on pain history and level of
disability, a supplementary analysis was carried out to
test for dierences between those with no history of pain
and a combined group of those with current pain and
those with no current pain but a history of pain. No
signicant dierence was demonstrated for performance
index scores between those with current or resolved
neck pain, and those with no history of neck pain
(F2,37 Z 3.31; P Z 0.077).

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)

previous studies have shown a dierence in CCFT


scores between groups with and without neck dysfunction. This study failed to nd such dierences. There are
many factors which might account for these results.
Participant fatigue may have been a factor with a rest
period of only 2 min between tests by each practitioner.
It is possible that patients achieved lower scores on
subsequent tests as fatigue of the deep cervical exors
developed and/or their pain levels increased. Eorts
were taken to avoid bias by ensuring that the order in
which participants were examined by practitioners was
randomised, as detailed in the Section 2.
The numbers in each group were small. There may
not have been adequate power for optimum statistical
analysis. This may explain why although correlations
were found between CCFT scores and pain intensity and
neck disability index scores, no dierences were found
between groups.
The participants were predominantly osteopathic
students who may have had more body awareness than
the general public. There is a possibility that their
knowledge of the action of the deep neck exor muscles
may have enhanced their performance compared to the
general population. The pressure biofeedback unit used
in the study is advertised to be accurate to G3 mmHg of
pressure, and although this is a potential source
of measurement error, the good inter-rater reliability
achieved in this study decreases the eect of this error.
The practitioners used in this study were essentially
novice users of the pressure biofeedback, with only 1 h of
formal training in use of CCFT prior to the study.

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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S. Hudswell et al. / International Journal of Osteopathic Medicine 8 (2005) 98e105

A signicant degree of correlation between performance


index and pain intensity was achieved by three raters
(practitioners 2e4). A signicant degree of correlation
between performance index and neck disability index
scores was achieved by two practitioners (practitioners 2
and 3). Only practitioner 3 showed a signicant correlation between activation score and pain intensity, and only
practitioner 2 showed a signicant correlation between
activation score and neck disability index. This highlights the possibility that the individual performance,
characteristics of the rater, plays an important role in
the usefulness of the CCFT. Practitioners with more
extensive experience in the use of pressure biofeedback
unit may perform better than the novice users in this
study, although this remains to be investigated. While
intra-rater and inter-rater reliabilities were found to
be excellent and good, respectively, it seems as though
two raters (practitioners 2 and 3) achieved much better
correlations between scores on the CCFT and neck
disability index scores or pain intensity, than the other
raters (practitioners 1 and 4).
A potential limitation of this study is in the use of the
original version of the CCFT (Clinical CCFT) instead
of the staged CCFT (Laboratory CCFT). The Clinical
CCFT was used in this study as it lent itself more easily
to the clinical setting. However, if the CCFT lacks
discriminative validity in the idealised research setting,
then one must seriously question the usefulness of this
test in the clinical setting. In further studies, researchers
should consider using a simplied version of the
Laboratory CCFT for increased accuracy.

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

Pressure held for 10 s (must be at least 22 mmHg).


Activation score minus baseline pressure.
Pressure increase multiplied by the number of completed holds.

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