Driehuis F1,2, Keijsers NLW3, Nijhuis-van der Sanden MWG1, de Bie RA4, Staal JB1, Hoogeboom TJ1
1Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, Netherlands, 2Royal Dutch Society for Physical Therapy (KNGF), Amersfoort, Netherlands, 3Sint Maartenskliniek Research, Development & Education, Nijmegen, Netherlands, 4Maastricht University, Maastricht, Netherlands
Background: Many infants are treated by manual therapists for asymmetry and positional preference of the head. Upper cervical dysfunction (UCD) is hypothesized as the underlying causative and provoking factor leading to reduced cervical range-of-motion. In clinical practice, the diagnosis of UCD is based on the assessment of upper cervical range-of-motion using the Flexion-Rotation-Test (FRT) and the Lateral-Flexion-Test (LFT). To date, even though treatment of infants lacks scientific evidence and is clinically based on the outcomes of these diagnostic tests, research on the reliability of the FRT and LFT is needed.
Purpose: To examine the inter-rater reliability of reported test outcomes and objectively measured range-of-motion between manual therapists.
Methods: In a cross-sectional observational study inter-rater reliability of the FRT and LFT in infants was determined. Three expert manual therapists participated in this study. Every manual therapist included 12 consecutive infants ( 6 months old) with a suspected case of UCD. Before assessment, possible contra-indications were checked. Two manual therapists independently assessed upper cervical mobility per infant. Thus each manual therapist assessed 12 infants as the first rater (R1) and 12 infants as the second rater (R2) in a counterbalanced order, resulting in a total of 36 infants. The FRT and LFT were performed by R1, followed by R2, to assess passive upper cervical mobility. Manual therapists reported test outcomes (reduced/normal range-of-motion). They were blinded for each other's outcomes. Simultaneously with the subjective range-of-motion assessment a three-dimensional motion analysis system consisting of two light-weight sensors, one placed on the forehead and one on the sternum, was used to objectively measure range-of-motion.
To compare reported outcomes of the FRT and LFT between manual therapists, we calculated the Cohen's kappa and observed, positive and negative agreement. To determine inter-rater reliability of objectively measured range-of-motion, we calculated intraclass correlation coefficients (ICCs) by using a two-way random model on absolute agreement .
Results: All 36 infants (10.4 weeks old) had a therapist-reported reduced passive upper cervical mobility. Percentages of agreement ranged between 57% and 86% and between 46% and 87% for the FRT and LFT, respectively. The inter-rater reliability between manual therapists varied for the FRT between slight (ĸ:0.195) and substantial (ĸ:0.657) and for the LFT between poor (ĸ:-0.077) and substantial (ĸ:0.727). Inter-rater reliability of objectively measured range-of-motion towards flexion-rotation and lateral flexion varied between poor and moderate (range ICC:-0.02 to 0.50). Mean differences in range-of-motion in degrees between manual therapists ranged from 8⁰ to 17⁰.
Conclusion(s): We combined the clinical practice of performance of tests by manual therapists with objectively measured ROM data. clinical interpretation of FRT and LFT showed high inconsistency between manual therapists. However, objectively measured ROM differed only slightly between manual therapists.
Implications: Clinical interpretation whether mobility is reduced seems to be more challenging for manual therapists than expected. Education of manual therapists should focus on interpretation of tests in a uniform way.
Keywords: Manual therapy, Reliability, Infants
Funding acknowledgements: This study was funded by the Dutch Association for Manual Therapy (NVMT).
Purpose: To examine the inter-rater reliability of reported test outcomes and objectively measured range-of-motion between manual therapists.
Methods: In a cross-sectional observational study inter-rater reliability of the FRT and LFT in infants was determined. Three expert manual therapists participated in this study. Every manual therapist included 12 consecutive infants ( 6 months old) with a suspected case of UCD. Before assessment, possible contra-indications were checked. Two manual therapists independently assessed upper cervical mobility per infant. Thus each manual therapist assessed 12 infants as the first rater (R1) and 12 infants as the second rater (R2) in a counterbalanced order, resulting in a total of 36 infants. The FRT and LFT were performed by R1, followed by R2, to assess passive upper cervical mobility. Manual therapists reported test outcomes (reduced/normal range-of-motion). They were blinded for each other's outcomes. Simultaneously with the subjective range-of-motion assessment a three-dimensional motion analysis system consisting of two light-weight sensors, one placed on the forehead and one on the sternum, was used to objectively measure range-of-motion.
To compare reported outcomes of the FRT and LFT between manual therapists, we calculated the Cohen's kappa and observed, positive and negative agreement. To determine inter-rater reliability of objectively measured range-of-motion, we calculated intraclass correlation coefficients (ICCs) by using a two-way random model on absolute agreement .
Results: All 36 infants (10.4 weeks old) had a therapist-reported reduced passive upper cervical mobility. Percentages of agreement ranged between 57% and 86% and between 46% and 87% for the FRT and LFT, respectively. The inter-rater reliability between manual therapists varied for the FRT between slight (ĸ:0.195) and substantial (ĸ:0.657) and for the LFT between poor (ĸ:-0.077) and substantial (ĸ:0.727). Inter-rater reliability of objectively measured range-of-motion towards flexion-rotation and lateral flexion varied between poor and moderate (range ICC:-0.02 to 0.50). Mean differences in range-of-motion in degrees between manual therapists ranged from 8⁰ to 17⁰.
Conclusion(s): We combined the clinical practice of performance of tests by manual therapists with objectively measured ROM data. clinical interpretation of FRT and LFT showed high inconsistency between manual therapists. However, objectively measured ROM differed only slightly between manual therapists.
Implications: Clinical interpretation whether mobility is reduced seems to be more challenging for manual therapists than expected. Education of manual therapists should focus on interpretation of tests in a uniform way.
Keywords: Manual therapy, Reliability, Infants
Funding acknowledgements: This study was funded by the Dutch Association for Manual Therapy (NVMT).
Topic: Paediatrics; Human movement analysis
Ethics approval required: Yes
Institution: Radboud university medical center
Ethics committee: CMO Arnhem-Nijmegen
Ethics number: NL.58488.091.16
All authors, affiliations and abstracts have been published as submitted.
