- Title
- The validity of clinical tests for craniovertebral instability
- Creator
- Osmotherly, Peter Grant
- Relation
- University of Newcastle Research Higher Degree Thesis
- Resource Type
- thesis
- Date
- 2014
- Description
- Research Doctorate - Doctor of Philosophy (PhD)
- Description
- The work contained in this thesis encompasses four studies to examine the validity of clinical testing for clinical instability of the craniovertebral region. Validity was explored through the utilisation and exploration of the constructs of convention, biological plausibility and empirical proof. Consensual validity for clinical testing was explored through a survey of knowledge and attitudes to instability testing in a nationwide survey involving 1528 Australian physiotherapists. Details of respondents’ understanding of the concept of instability, potential clinical presentations of patients with segmental hypermobility of the upper cervical spine, knowledge of published clinical stress tests, attitudes toward performing these clinical tests and inclusion of craniovertebral testing procedures in clinical guidelines were all assessed. On the basis of the information returned, it appears that the level of knowledge and understanding of these disorders, their clinical presentation, assessment and their risk factors is low. Understanding of the clinical testing manoeuvres was also poor, with the majority of respondents never applying these tests clinically. Completion of post-graduate coursework in musculoskeletal physiotherapy clearly improved exposure to these concepts and tests in respondents, but did not significantly affect use of testing for screening prior to treatment of the upper cervical spine overall. Consensual validity for clinical testing of craniovertebral instability must be considered to be low based upon the absence of agreement of the existence, presentation and assessment of the disorder. Biological plausibility of testing was explored through examination of the morphology of the ligaments of the craniovertebral region. Observations made during the dissection of 11 cadaveric specimens were mostly in accordance with descriptions of the anatomy upon which the clinical test procedures have been based. However, the tectorial membrane was observed to be a more complex structure than has previously been understood with its fibre arrangement suggesting a role as a potentially limiting structure to axial rotation of the upper cervical segments. The existence of the previously reported ‘atlantal’ portion of the alar ligaments was also challenged. It was not observed in any specimen examined and the presence of these bands of tissue in any individual should be considered an anatomical variant. Overall, the gross morphology of the craniovertebral ligaments observed being consistent with the basis of the clinical tests confers face validity on the testing procedures. The biological basis for testing was further explored using magnetic resonance imaging of six specimens at high (4.6T) and clinical (3.0T) definition acquisitions. Observations were confirmed by dissection and the accuracy of measurements and observations assessed. Again, the gross morphology was consistent with the structural assumptions underpinning the clinical tests, thus enhancing their face validity. Clinical acquisitions were compared using three different sequences to assess the optimal acquisition sequence to be used in subsequent patient studies. Proton density-weighted sequences were found to be superior in identification, delineation and measurement of the ligaments of this region. Empirical proof that clinical tests are capable of influencing the ligaments of this region was addressed in the final study. The upper cervical spines of 16 healthy volunteers were imaged using MRI in both neutral and end-range clinical test positions. Ligaments were assessed using both direct measurement and indirect estimates of bony displacement. Statistically significant changes in ligament dimension were demonstrated for the ligaments in all tests examined. Direct evidence that the ligament may be influenced in a predictable manner through the imposition of clinical tests provides a strong case for the establishment of construct validity for each of these described clinical tests. Through utilising the three axioms of convention, biological plausibility and empirical proof, a number of aspects of the validity of clinically testing the craniovertebral region for instability have been assessed. Whilst the consensual validity of testing appears poor, the case for face validity and construct validity for the ligament stress tests is strong suggesting that further research is warranted which may now potentially involve individuals with demonstrable instabilities of this region.
- Subject
- cervical spine; instability; craniovertebral; clinical testing
- Identifier
- http://hdl.handle.net/1959.13/1040273
- Identifier
- uon:13761
- Rights
- Copyright 2014 Peter Grant Osmotherly
- Language
- eng
- Full Text
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| Thumbnail | File | Description | Size | Format | |||
|---|---|---|---|---|---|---|---|
| View Details Download | ATTACHMENT01 | Abstract | 165 KB | Adobe Acrobat PDF | View Details Download | ||
| View Details Download | ATTACHMENT02 | Thesis | 12 MB | Adobe Acrobat PDF | View Details Download |