Identifiers suggestive of clinical cervical spine instability: a delphi study of

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Phys Ther. 2005 Sep;85(9):895-906.

Identifiers suggestive of clinical cervical spine instability: a

delphi study of physical therapists.

Cook C, Brismee JM, Fleming R, Sizer PS Jr.

Duke University Medical Center 3907, Durham, NC 27710, USA.

BACKGROUND AND PURPOSE: 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.

SUBJECTS: 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. "

DISCUSSION AND CONCLUSION: 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.