The validity of clinical tests for craniovertebral instability

Internationally, manual therapy has moved towards formalised guidelines for pre-manipulative screening of the cervical spine. A controversial aspect to emerge from this involves craniovertebral instability (CVI) testing. This study examined current practice, knowledge and attitudes of Australian physiotherapists regarding pre-manipulative testing for CVI. Members of Musculoskeletal Physiotherapy Australia were surveyed by formally validated questionnaire. Sub-group analysis was performed by post-graduate musculoskeletal qualification. The response rate was 37.8%. Respondents provided differing definitions of CVI; 46.5% describing loss of anatomical integrity and 24.9% a biomechanical problem. Over half indicated they rarely or never used stress tests for CVI screening. Of 42 published signs and symptoms associated with CVI, seven were identified by more than 50% of respondents. Of published disorders associated with CVI, four were considered worthy of testing by more than 30% of respondents. Support for inclusion of information on CVI inpre-manipulative guidelineswas given by 87% of respondents. Recommendations for screening tests received less support, particularly among physiotherapists holding post-graduate musculoskeletal qualifications (p 1⁄4 0.0002). These results indicate disagreement regarding the nature and presentation of CVI. Clinical testing is inconsistent, reflecting underlying confusion about CVI. Currently, there is not an appropriate level of knowledge or willingness to recommend guidelines for CVI screening. 2010 Elsevier Ltd. All rights reserved.

[1]  R. Rothman,et al.  Atlanto-occipital hypermobility. , 1978, The Orthopedic clinics of North America.

[2]  P. Shrout.  Measurement reliability and agreement in psychiatry , 1998, Statistical methods in medical research.

[3]  T. Flynn,et al.  Upper cervical ligament testing in a patient with os odontoideum presenting with headaches. , 2008, The Journal of orthopaedic and sports physical therapy.

[4]  A. Cave.  On the Occipito-Atlanto-Axial Articulations. , 1934, Journal of anatomy.

[5]  R. Swinkels,et al.  Pathogenesis of upper cervical instability. , 1996, Manual therapy.

[6]  M M Panjabi,et al.  Quantitative anatomy of cervical spine ligaments. Part I. Upper cervical spine. , 1991, Journal of spinal disorders.

[7]  V. Hinck,et al.  Measurement of the atlanto-dental interval in the adult. , 1960, The American journal of roentgenology, radium therapy, and nuclear medicine.

[8]  G. Uitvlugt,et al.  Clinical assessment of atlantoaxial instability using the Sharp-Purser test. , 1988, Arthritis and rheumatism.

[9]  G. C. Gorniak,et al.  Radiographic Assessment and Reliability Study of the Craniovertebral Sidebending Test , 1998 .

[10]  C. Pfirrmann,et al.  MR morphology of alar ligaments and occipitoatlantoaxial joints: study in 50 asymptomatic subjects. , 2001, Radiology.

[11]  R. P. Fabio,et al.  Manipulation of the cervical spine: risks and benefits. , 1999, Physical therapy.

[12]  P. Sturm,et al.  Intraobserver reproducibility and interobserver reliability of cervical spine measurements. , 2000, Journal of pediatric orthopedics.

[13]  M. O'Malley,et al.  A pictorial review of atlanto-axial rotatory fixation: key points for the radiologist. , 2001, Clinical radiology.

[14]  R. Putz,et al.  A geometrical model of vertical translation and alar ligament tension in atlanto-axial rotation , 2012, European Spine Journal.

[15]  M. Harris,et al.  Anatomical and roentgenographic features of atlantooccipital instability. , 1993, Journal of spinal disorders.

[16]  N. Gilhus,et al.  MRI assessment of normal ligamentous structures in the craniovertebral junction , 2001, Neuroradiology.

[17]  J. Meadows.  The Sharp-Purser Test: A Useful Clinical Tool or an Exercise in Futility and Risk? , 1998 .

[18]  M M Panjabi,et al.  Functional Anatomy of the Alar Ligaments , 1987, Spine.

[19]  G. Locke,et al.  Atlas-dens interval (ADI) in children: a survey based on 200 normal cervical spines. , 1966, The American journal of roentgenology, radium therapy, and nuclear medicine.

[20]  E Schneider,et al.  Biomechanics of the craniocervical region: The alar and transverse ligaments , 1988, Journal of orthopaedic research : official publication of the Orthopaedic Research Society.

[21]  J. Basmajian,et al.  Grant's method of anatomy , 2016 .

[22]  R. Hensinger.  Osseous Anomalies of the Craniovertebral Junction , 1986, Spine.

[23]  R. Swinkels,et al.  Upper cervical instability: fact or fiction? , 1996, Journal of manipulative and physiological therapeutics.

[24]  G. Albrektsen,et al.  Clinical assessment techniques for detecting ligament and membrane injuries in the upper cervical spine region--a comparison with MRI results. , 2008, Manual therapy.

[25]  R. Swinkels,et al.  Upper cervical instability: are clinical tests reliable? , 1997, Manual therapy.

[26]  K. Okazaki.  [Anatomical study of the ligaments in the occipito-atlantoaxial complex]. , 1995, Nihon Seikeigeka Gakkai zasshi.

[27]  B. Spector.  Anatomy: A Regional Study of Human Structure. , 1963 .

[28]  K. S. Ludwig.  Über das Ligamentum alare dentis epistrophei des Menschen , 2004, Zeitschrift für Anatomie und Entwicklungsgeschichte.

[29]  W. Aspinall.  Clinical testing for the craniovertebral hypermobility syndrome. , 1990, The Journal of orthopaedic and sports physical therapy.

[30]  A. Sullivan,et al.  Subluxation of the atlanto-axial joint, sequel to inflammatory processes of the neck. , 1949, The Journal of pediatrics.

[31]  K. Refshauge,et al.  Clinical Guidelines for Assessing Vertebrobasilar Insufficiency in the Management of Cervical Spine Disorders , 2006 .

[32]  F. Jones.  BUCHANAN'S MANUAL OF ANATOMY , 1950, The Ulster Medical Journal.

[33]  T. Douglas,et al.  Digital Radiographic Measurement of the Atlantodental Interval in Children , 2007, Journal of pediatric orthopedics.

[34]  K. Grimmer,et al.  Non-steroidal anti-inflammatory drugs (NSAIDs): physiotherapists' use, knowledge and attitudes. , 2002, The Australian journal of physiotherapy.

[35]  J. Clarys,et al.  3D morphometry of the transverse and alar ligaments in the occipito–atlanto–axial complex: An in vitro analysis , 2007, Clinical anatomy.

[36]  D. Rivett,et al.  Knowledge and use of craniovertebral instability testing by Australian physiotherapists. , 2011, Manual therapy.

[37]  P. Hodges,et al.  Patients With Neck Pain Demonstrate Reduced Electromyographic Activity of the Deep Cervical Flexor Muscles During Performance of the Craniocervical Flexion Test , 2004, Spine.

[38]  D. Rivett,et al.  Complications Arising from Spinal Manipulative Therapy in New Zealand , 1997 .

[39]  C. Hughes.  Kinesiology: The Mechanics and Pathomechanics of Human Movement , 2004 .

[40]  E. Ernst.  Manipulation of the cervical spine: a systematic review of case reports of serious adverse events, 1995–2001 , 2002, The Medical journal of Australia.

[41]  L. Wagner,et al.  Radiologic diagnosis of traumatic occipitovertebral dissociation: 1. Normal occipitovertebral relationships on lateral radiographs of supine subjects. , 1994, AJR. American journal of roentgenology.

[42]  P. Gibbons,et al.  Manipulation of the Spine, Thorax and Pelvis: An Osteopathic Perspective , 2000 .

[43]  Hyung-Jin Kim,et al.  MR imaging of the alar ligament: morphologic changes during axial rotation of the head in asymptomatic young adults , 2002, Skeletal Radiology.

[44]  L. Ada,et al.  Prevalence of thumb pain in physical therapists practicing spinal manipulative therapy. , 2003, Journal of hand therapy : official journal of the American Society of Hand Therapists.

[45]  A. Solomon.  Anatomy: A Regional Study of Human Structure , 1960 .

[46]  L. Testut,et al.  Traité d'anatomie humaine , 1905 .

[47]  P. Osmotherly,et al.  The relationship between dens height and alar ligament orientation: a radiologic study. , 2011, Journal of manipulative and physiological therapeutics.

[48]  H. Niibayashi.  Atlantoaxial Rotatory Dislocation: A Case Report , 1998, Spine.

[49]  B. Chesworth,et al.  Post-motor vehicle accident alar ligament laxity. , 1992, The Journal of orthopaedic and sports physical therapy.

[50]  M. Panjabi.  The stabilizing system of the spine. Part I. Function, dysfunction, adaptation, and enhancement. , 1992, Journal of spinal disorders.

[51]  J. Bogousslavsky,et al.  Cerebrovascular Complications of Neck Manipulation , 2008, European Neurology.

[52]  A. G. Gibb.  Unusual complications of tonsil and adenoid removal. , 1969, The Journal of laryngology and otology.

[53]  J Dvorak,et al.  Effects of Alar ligament transection on upper cervical spine rotation , 1991, Journal of orthopaedic research : official publication of the Orthopaedic Research Society.

[54]  V K Goel,et al.  Ligamentous Laxity Across C0‐C1-C2 Complex: Axial Torque‐Rotation Characteristics Until Failure , 1990, Spine.

[55]  M. Benjamin,et al.  Expression of a wide range of fibrocartilage molecules at the entheses of the alar ligaments - possible antigenic targets for rheumatoid arthritis? , 2003, The Journal of rheumatology.