Manual Therapy 21 (2016) 159e164

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Manual Therapy
journal homepage: www.elsevier.com/math

Original article

3D motion reliability of occipital condylar glide testing: From concept

to kinematics evidence
phane Sobczak a, b, Walid Salem a, Ve
Benot Beyer a, b, c, Ste ronique Feipel b,
Pierre-Michel Dugailly a, b, *
a
Research Unit in Osteopathy, Faculty of Motor Sciences, Universit
e Libre de Bruxelles (ULB), Brussels, Belgium
b
Laboratory of Functional Anatomy, Faculty of Motor Sciences, Universite Libre de Bruxelles (ULB), Brussels, Belgium
c
Laboratory of Anatomy, Biomechanics and Organogenesis (LABO), Faculty of Medicine, Universit e Libre de Bruxelles (ULB), Brussels, Belgium

a r t i c l e i n f o a b s t r a c t

Article history: Background: To date, segmental data analyzing kinematics of occipital condylar testing or mobilization is
Received 25 February 2015 lacking.
Received in revised form Objectives: The objective of this study was to assess occipitoatlantal 3D motion components and to
3 July 2015
analyze inter- and intra-rater reliability during in vitro condylar glide test.
Accepted 9 July 2015
Methods: To conduct this study, four fresh cadavers were included. Dissection was carried out to ensure
technical clusters placement to skull, C1 and C2. During condylar glide test, bone motion data was
Keywords:
computed using an optoelectronic system. The reliability of motion kinematics was assessed for three
Kinematics
Upper cervical spine
skilled practitioners performing two sessions of 3 trials on two days interval.
Reliability Findings: During testing, average absolute motion ROM (SD) were up to 4.1 2.1
, 0.7 1.3
and
Condylar glide 10.3 2.5
for occipitoatlantal lateral bending, axial rotation and exion-extension, respectively. For
position variation, magnitudes were 2.3 1.8 mm, 1.1 1.3 mm and 2.6 0.8 mm for anteroposterior,
cephalocaudal and mediolateral displacements. Concerning motion reliability, variation ranged from 0.6

to 3.4
and from 0.3 mm to 1.6 mm for angular displacement and condyle position variation, respectively.
In general, good to excellent agreement was observed (ICC ranging from 0.728 to 0.978) for the same
operator, while consistency was limited to lateral/side bending and lateral condyle displacement be-
tween operators, with respective ICCs of 0.800 and 0.955.
Conclusions: This study shows specic motion patterns involving extension and lateral bending of the
occipitoatlantal level for anterior condylar glide test. In addition, condyle position variation demon-
strated coupled components in forward and heterolateral directions. However, task seems not to be side
specic. In general, reliability of 3D motion components showed good intra-operator agreement and
limited inter-operator agreement.
2015 Elsevier Ltd. All rights reserved.

1. Introduction forces/torques on specic bony structures (e.g. articular pillar,

Manual techniques are frequently used for both treating and
assessing functional impairments of the musculoskeletal system
(Gross et al., 2004; Schroeder et al., 2013). Concerning the cervical
spine, spinal motion palpation (SMP) is routinely proposed to eval-
uate segmental and/or regional vertebral movements (Humphreys
et al., 2004; van Trijffel et al., 2010) by the application of manual
* Corresponding author. Research Unit in Osteopathy, Faculty of Motor Sciences,
 Libre de Bruxelles (ULB), 808 route de Lennik, CP 640, 1070 Brussels,
Universite
Belgium.
E-mail address: pdugaill@ulb.ac.be (P.-M. Dugailly).
spinous process) (Snodgrass et al., 2009). However, a systematic re-
view concluded that reliability of SMP reached at best a fair inter-
examiner agreement (van Trijffel et al., 2005). In contrast, quantita-
tive and qualitative agreement of SMP were found to be sufcient for
clinical relevance for both the upper (Piva et al., 2006) and the lower
cervical spine (Manning et al., 2012) among neck pain patients.
Besides passive motion assessment, SMP have been usually
proposed to detect painful sites (Jull et al., 1997) or to mobilize
vertebral joints in a particular direction using different grades or
magnitude of motion range (Hartman, 1997; Jull, 2002; Greenman,
2003). Consequently, several mobilization approaches (with or
without impulsion) are suggested for treating various types of neck

http://dx.doi.org/10.1016/j.math.2015.07.005
1356-689X/ 2015 Elsevier Ltd. All rights reserved.
160 B. Beyer et al. / Manual Therapy 21 (2016) 159e164
pain (Dunning et al., 2012; Lopez-Lopez et al., 2015), cervicogenic
dizziness (Reid et al., 2014) and headache (Hall et al., 2007; Youssef
and Shanb, 2013; Shin and Lee, 2014).
Despite this wide clinical use, segmental SMP is essentially
based on conceptual approaches and traditions rather than on
quantitative data analysis, and scientic evidence is sparse.
From a biomechanical point of view, in-vitro studies reported 3D
arthrokinematic features following C1eC2 mobilization (Cattrysse
et al., 2007, 2010) or upper cervical spine (UCS) manipulation
(Dugailly et al., 2014a). Similarly to SMP, these authors have dened
substantial intra- and inter-rater reliability for the axial rotation
component (Cattrysse et al., 2009) and average regional variations
(C0eC2) reached up to 1
and 6
(Dugailly et al., 2014a).
However, currently, both segmental and/or global kinematics
data are still lacking to describe specic manual procedures (i.e.
mobilization and motion palpation) applied at the occipitoatlantal
level of the UCS.
The purposes of this study were (1) to assess 3D kinematics and
(2) motion reproducibility (intra- and inter-practitioner) of the
upper cervical spine during segmental mobilization dened as the
occipital condylar glide test (Greenman, 2003).
2. Material and methods
2.1. Study design
The experimental protocol was based on a previous study
describing in-vitro upper cervical spine motion during mobiliza-
tions with impulse (Dugailly et al., 2014a).
Four fresh anatomical specimens were used to conduct this
study (3 females, 1 male; age 87 (SD 9) years). Several minimal
incisions were performed at the lateral and anterolateral upper
neck regions to access UCS vertebrae for ensuring technical clusters
xation. Muscles were kept intact to maintain the cervical region
under close to normal conditions (Fig. 1). In total three technical
clusters were used for the occiput, atlas (C1) and axis (C2).
Three practitioners (8e20 years of experience) carried out an
upper cervical test at the occipitoatlantal level (C0eC1) as described
by Greenman (2003) for assessing the occipital condylar glide.
The practitioner's hands grasped the posterior aspects of each
mastoid process (contact with the second metacarpophalangeal
joint area) while the thumbs took contact with the zygomatic
arches. To complete an anterior glide of the occipital condyle, the
Fig. 1. Experimental setting showing three technical clusters screwed in the skull, atlas
and axis. Assessment of left occipital condylar glide in left lateral bending, extension
and right rotation is visualized.
practitioner applied successive motion components of extension
(backward bending), ipsilateral side bending and contralateral axial
rotation (See supplementary material).
Supplementary video related to this article can be found at
http://dx.doi.org/10.1016/j.math.2015.07.005.
The present testing protocol consisted of achieving three
consecutive repetitions of anterior condylar glides by each practi-
tioner and for both sides. Practitioners were selected in a random
order (random number table) to achieve each testing for two ses-
sions (two days interval).
Prior to motion testing, each specimen including technical
clusters underwent a computed tomography (CT) assessment
(Siemens SOMATOM, helical mode, reconstruction: slice
thickness 1 mm, interslice spacing 1 mm, image data format
DICOM 3.0). CT data were processed to provide 3D anatomical
modeling and for further registration of imaging and kinematics
data (see below).
2.2. Motion data processing
An optoelectronic system (Vicon 612, 8 cameras, Oxford,
United Kingdom; sampling frequency: 200 Hz) was used to register
technical cluster displacements of each bone of interest during task
achievement. Then motion data were processed for data fusion to
provide kinematics analysis and anatomical motion representation
using dedicated software (LhpFusionBox). This validated procedure
is detailed elsewhere (Van Sint Jan et al., 2002) and was recently
adapted for the UCS during high velocity low amplitude manipu-
lation (Dugailly et al., 2014a).
Motion analysis used computation of angular displacement
derived from helical axis data (Woltring, 1994). In the present
study, decomposition of helical axis rotation into helical angles was
adapted to provide angular displacements in a local anatomical
coordinate system (ACS) as previously proposed (Dugailly et al.,
2010). Thus, anatomical motion components such as lateral
bending (LB), axial rotation (AR) and exion-extension were
dened around the x, y and z-axes, respectively (Fig. 2). Addition-
ally, condylar positions (i.e. position vector magnitude in mm on
each ACS axes) were computed in the same ACS considering the top
of each condyle. The coordinates of the latter were dened
following a virtual palpation procedure of anatomical landmarks
(Dugailly et al., 2011). Thus, antero-posterior, cephalocaudal and
medio-lateral condyle position variation magnitudes were respec-
tively depicted along the x, y and z-axes.
2.3. Statistical analysis
Means and standard deviations of both angular displacements
and position variation were calculated to describe motion data.
Kinematics reliability was analyzed using computation of inter- and
intra-practitioner (within- and between sessions) root mean square
errors (RMSE) as well as intraclass correlation coefcients (ICCs).
3. Results
All specimens were used for the entire testing protocol. In total,
36 condylar glide tests were performed at C0eC1 level for each
specimen.
3.1. Kinematics outcomes
Average motion data (3 repetitions, 2 sessions) are presented in
Table 1 for angular displacements and condyle position variation
magnitudes for left and right condylar glide tests distinctly. Larger
angular displacement magnitudes were demonstrated for
 B. Beyer et al. / Manual Therapy 21 (2016) 159e164 161

condyle position variations. On average, intra-operator RMSE

ranged from 0.6
to 1.4
and from 0.9
to 3.4
for within- and
between-session comparisons, respectively. For the extension
component, maximal variation was up to 6.2
for between-session
analysis. Similar data were observed for inter-operator reliability.
Considering the substantial motion components (e.g., extension
and lateral bending), these variations corresponded from 23 to 34%
of the absolute ranges.
ICCs demonstrated good to excellent intra-operator agreements
for all motion components. In contrast, consistency was only
demonstrated between practitioners for lateral bending.
Fig. 3 illustrates the angular displacement components of three
consecutive maneuvers of right C0eC1 motion glide for one prac-
titioner. A good similarity in magnitude was observed.
Concerning reliability of condyle position variation, average
RMSE magnitudes ranged from 0.3 mm to 1 mm and up to 1.6 mm
for intra- and inter-operator respectively. Maximal variations (up to
3 mm) were observed between operators. Good intra-operator and
inter-operator agreements were observed for AP and lateral
condyle positions, respectively, with ICCs ranging from 0.73 to 0.99
(Table 3). The remaining ICCs were found to be fair to poor.
Fig. 4 gives an example depicting the condyle position during
left and right anterior condylar glides. Note the similarity in motion
patterns and magnitudes for both condyles as conrmed by tted
polynomial functions. In addition, similar direction of variation is
observable for anterior and lateral positions. In contrast, cepha-
locaudal condyle position variation is opposite between condyles
with a caudal displacement ipsilateral to the tested condyle.

4. Discussion

Spinal motion palpation represents a usual clinical procedure to

Fig. 2. Anatomical model and local reference system for skull and atlas with x-, y- and
z-axes pointing forward, upward and to the right, respectively. Posterior, right lateral
and superior views in neutral (A) and for the left condylar glide test (B). Note the left
lateral bending and the extension of the skull relative to C1.
extension and lateral bending while axial rotation component was
negligible. Lateral bending was ispilateral to the side of condylar
glide examination.
Overall, during anterior condylar glide test, position variation
occurred principally in anterior and contralateral directions with
average magnitudes (in absolute value) ranging from 1.8 mm to
2.6 mm. In addition, these components were similar in magnitude
as well as in direction for both condyles regardless of the side
tested. Cephalocaudal position variation had opposite directions
between left and right condyles. Note that small magnitudes (up to
1 mm) occurred for this motion component.
3.2. Kinematics reliability
Table 2 summarizes intra- and inter-practitioner reliability
analysis using RMSE and ICCs for angular displacements and
assess intervertebral movement by means of quantitative or qual-
itative appraisal (Humphreys et al., 2004; Marcotte et al., 2005; van
Trijffel et al., 2010; Cooperstein et al., 2013). The present study
attempted to determine both 3D kinematics of occipitoatlantal
joints and inter- and intra-operator reliability of an SMP procedure
consisting in an anterior condylar glide assessment (Greenman,
2003). The ndings indicate that this task consisted in combined
angular motions including mainly extension and lateral/side
bending. Extension was the substantial motion component with an
average of 10
compared to an average of 4
for lateral bending.
These motion components seem to be consistent with the technical
features of the procedure described in the literature (Greenman,
2003).
When compared to other studies, motion magnitudes agreed
with in-vitro and in-vivo data for lateral/side bending and exion-
extension (Karhu et al., 1999; Ishii et al., 2006; Cattrysse et al., 2007;
Dugailly et al., 2010), but only one of these studies was conducted
using a manual procedure protocol (Cattrysse et al., 2007, 2015).
Unlike extension and lateral bending, axial rotation was a
negligible motion component, which is in agreement with the
limited motion range reported for this level (Ishii et al., 2004;
Takasaki et al., 2011).

Table 1
Kinematics data of occipital condylar glide test (average (SD)).

Test side ROM (
) Condyle position variation (mm)

Left condyle Right condyle

LB AR FE AP CC Lateral AP CC Lateral

Right 3.6 (1.0) 0.5 (1.8) 9.6 (2.4) 2.3 (1.8) 0.7 (1.3) 2.6 (0.8) 2.3 (1.6) 0.6 (1.4) 2.6 (0.8)
Left 4.1 (2.1) 0.1 (2.4) 10.3 (2.5) 1.8 (1.1) 0.1 (1.4) 2.0 (1.4) 2.2 (1.0) 1.1 (1.3) 2.0 (1.3)

Abbreviations: LB (lateral bending), AR (axial rotation), FE (exion extension), AP (anteroposterior) and CC (cephalocaudal).
162 B. Beyer et al. / Manual Therapy 21 (2016) 159e164

Table 2
Reliability of kinematics during condylar glide test.

ROM (
) Condyle position variation (mm)

Left condyle Right condyle

LB AR FE AP CC Lateral AP CC Lateral

Intra operator
Within session RMSE 0.6 (0.5) 0.7 (0.4) 1.4 (0.9) 0.3 (0.3) 0.4 (0.3) 0.4 (0.4) 0.4 (0.3) 0.3 (0.3) 0.4 (0.4)
Max 1.8 1.4 4.2 1.0 1.4 1.9 1.0 1.2 2.0
Between session RMSE 0.9 (0.4) 0.9 (0.6) 2.4 (1.9) 0.6 (0.5) 1.0 (0.5) 0.6 (0.4) 0.6 (0.5) 0.8 (0.4) 0.6 (0.4)
Max 1.8 2.1 6.2 1.6 1.8 1.5 1.8 1.7 1.5
Inter operator
RMSE 0.9 (0.2) 1.0 (0.5) 3.4 (0.9) 1.6 (0.7) 1.4 (1.0) 1.6 (0.7) 1.5 (0.5) 1.6 (0.8) 1.6 (0.8)
Max 1.1 1.4 4.4 3.1 1.9 2.5 2.0 2.0 2.5

Abbreviations: RSME (root mean square error), LB (lateral bending), AR (axial rotation), FE (exion extension), AP (anteroposterior) and CC (cephalocaudal).

condyle displayed a cephalic position variation that is consistent

with this specic SMP pattern.
The second objective of this study was to examine the reliability
of the applied 3D motion among different practitioners and at two
days interval. Takasaki et al. (2011) examined the reliability of the
UCS segments by assessing exion rotation using MRI and found
good to excellent reliability. However, this study only focused on
axial rotation that represents the more negligible motion compo-
nent for the occipito-atlantal level. Further, our outcomes agree
with a previous study during high velocity low amplitude thrusts of
the upper cervical spine by indicating low intra- and inter-
variations (up to 4
) for the atlantoaxial level (Dugailly et al.,
2014a). Similarly, a recent study conrmed substantial inter-
examiner reliability for the axial rotation component at C1eC2
(Gianola et al., 2015). However, for the latter, fair ICCs were found
for the non-intended motion components at the adjacent occipi-
Fig. 3. Skull kinematics patterns relative to C1 during right condyle glide test (three toatlantal level. In contrast, the present results demonstrated good
repetitions). Angular displacements (in degrees) for lateral bending (red), axial rotation intra-operator agreements for all motion components while con-
(green) and exion-extension (blue). Positive values represent right lateral bending,
sistency was limited to lateral/side bending only for inter-operator
left axial rotation and extension. (For interpretation of the references to color in this
gure legend, the reader is referred to the web version of this article). reliability. On the other hand, average RMSE conrmed low varia-
tions in magnitude not exceeding 4.4
, though this data repre-
sented up to 34% of the absolute range dependent on the
On the contrary, the condylar glide test is usually assumed to substantial motion components.
assess condyle motion at one side selectively. The current results Besides, condyle position variation demonstrated good agree-
show, by means of the position of the condylar top, that condyle ments for AP and lateral directions between repeated measure-
position magnitude seemed not to be related to the intended side of ments by the same practitioner and only for lateral direction
the test. Considering non-intended motion components, similar between practitioners.
ndings were mentioned during atlanto-axial manipulation The high reliability of both lateral bending and lateral position
(Cattrysse et al., 2015). Regarding the present outcomes, both variation may be related to the technical procedure that described
condyles displayed anterior and lateral position variations in the these two motion components as the main components achieved
same direction during the task. Nevertheless, these magnitudes during the task.
were very limited and the antero-posterior component showed a It is also interesting to underline that, regarding LB, reliability
lower determination coefcient (Fig. 4). data obtained during condylar glide test are consistent with results
Cephalocaudal condyle position variation was very limited, but obtained for UCS high velocity low amplitude manipulation, for
opposite in direction between right and left condyle. The tested pre-positioning as well as for impulse (Dugailly et al., 2014b). Note
condyle exerted a slight caudal displacement while the opposite that LB is also a prime motion component achieved to focalize
motion end feel during both condylar glide test and pre-positioning
during UCS manipulation (Dugailly et al., 2014b). The procedure has
Table 3 been described according the concept of multiple component
Intraclass correlation coefcients for angular displacement (ROM) and condyle po- techniques emphasizing the minimization of motion components
sition variation.
during task (Hartman, 1997).
Intraoperator Interoperator There are several limitations to this study that may be pointed
ROM LB 0.978 0.955 out. First, ndings are obtained from in-vitro experimentation and
AR 0.942 0.477 the age-related degenerative changes should be taken into
FE 0.868 0.102 consideration. However, neither major stiffness increase nor range
Condyle position variation AP 0.728 0.341 of motion limitation was observed during the motion palpation
CC 0.160 0.273
Lateral 0.998 0.800
procedure. Although inter-individual variations in terms of soft
tissue stiffness, dysfunction or morphology are likely to lead vari-
Abbreviations: LB (lateral bending), AR (axial rotation), FE (exion extension), AP
ations of results, the small sample size should also be considered.
(anteroposterior) and CC (cephalocaudal).
 B. Beyer et al. / Manual Therapy 21 (2016) 159e164
Fig. 4. Right condyle position patterns related to C1 following right and left condylar glide tests (raw data and fth order polynomial functions for one trial). Anteroposterior (red),
cephalocaudal (green) and mediolateral (blue) condyle displacements. Positive values represent anterior, cephalic and right condyle position variations. (For interpretation of the
references to color in this gure legend, the reader is referred to the web version of this article).
Secondly, condyle position was appraised based on location
variations of an anatomical landmark (the top of the condyle). The
choice of this particular bony landmark was assumed to better
reect the main objective of the task by depicting the glide features
of the occipital condyle instead of the location of the condylar center
as mentioned previously (Chancey et al., 2007). Similar consider-
ations were recently debated for the atlanto-axial level during high
velocity low amplitude manipulation (Buzzatti et al., 2015).
5. Conclusions
Anterior glide motion palpation shows specic motion patterns
involving extension and lateral bending of the occipitoatlantal
level. These motion components were consistent regarding the
technical description of the procedure. However, it seems that
condylar glide test is not specic to the side assessed using this
procedure. Reliability of all motion components was shown for
repeated measurements and only for lateral bending between
practitioners. In addition, condyle position variation demonstrated
coupled components in forward and contralateral directions to the
side of the motion examination. In general, lateral bending motion
and lateral condyle position variation were the most representative
parameters concerning reliability.
Further research is needed to conrm the present results and to
assess kinematics features of various manual palpation procedures.
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