European Spine Journal 2017 (Sep); 26 (9): 2225–2241 ~ FULL TEXT
Lemeunier N, da Silva-Oolup S, Chow N, Southerst D, Carroll L, Wong JJ, Shearer H, Mastragostino P, Cox J, Côté E, Murnaghan K, Sutton D, Côté P
Institut Franco-Européen de Chiropraxie,
72 chemin de la Flambère,
31300, Toulouse, France.
OBJECTIVE: To determine the reliability and validity of clinical tests to assess the anatomical integrity of the cervical spine in adults with neck pain and its associated disorders.
METHODS: We updated the systematic review of the 2000-2010 Bone and Joint Decade Task Force on Neck Pain and its Associated Disorders. We also searched the literature to identify studies on the reliability and validity of Doppler velocimetry for the evaluation of cervical arteries. Two independent reviewers screened and critically appraised studies. We conducted a best evidence synthesis of low risk of bias studies and ranked the phases of investigations using the classification proposed by Sackett and Haynes.
RESULTS: We screened 9022 articles and critically appraised 8 studies; all 8 studies had low risk of bias (three reliability and five validity Phase II-III studies). Preliminary evidence suggests that the extension-rotation test may be reliable and has adequate validity to rule out pain arising from facet joints. The evidence suggests variable reliability and preliminary validity for the evaluation of cervical radiculopathy including neurological examination (manual motor testing, dermatomal sensory testing, deep tendon reflexes, and pathological reflex testing), Spurling's and the upper limb neurodynamic tests. No evidence was found for doppler velocimetry.
CONCLUSIONS: Little evidence exists to support the use of clinical tests to evaluate the anatomical integrity of the cervical spine in adults with neck pain and its associated disorders. We found preliminary evidence to support the use of the extension-rotation test, neurological examination, Spurling's and the upper limb neurodynamic tests.
KEYWORDS: Neck pain, Assessment, Diagnosis, Neurological tests, Vertebrobasilar insufficiency, Stenosis, Dissection, stroke, Doppler velocimeter
From the FULL TEXT Article:
Neck pain and its associated disorders (NAD) are common in
the general population. More than 80% of individuals
experience NAD during their lifetime and 30–50% of the
general adult population reports neck pain annually. [1, 2]
Most neck pain is benign, but patients with neck pain may
present with serious underlying pathologies such as cervical
spine radiculopathy, fracture, cervical artery dissections,
infection, or neoplasm. Accurate diagnoses are necessary to
guide patient management and inform prognosis.  However,
ruling out pathologies can be challenging and requires
an approach that is based on valid and reliable tests.
Previous systematic reviews found limited evidence to
support the utility of commonly used clinical tests to assess
the anatomical integrity of the cervical spine. [4, 5]
Specifically, the clinical utility of provocation tests for
cervical radiculopathy and doppler velocimetry for vascular
lesions of the cervical arteries remains controversial. [6–14] In 2008, the Bone and Joint Decade 2000–2010
Task Force on Neck Pain and Its Associated Disorders
[Neck Pain Task Force (NPTF)] conducted a systematic
review of the literature on the diagnosis and assessment of
neck pain.  The Neck Pain Task Force found three
validity studies of clinical tests that assess the anatomical
integrity of the cervical spine in patients with NAD. [16–18] The studies reported that sensitivity of the Spurling’s
test and the upper limb neurodynamic test (ULNT)/
upper limb tension test (ULTT) ranged from 77 to 90%,
and specificity ranged from 22 to 94% when compared
with gold standards [MRI, nerve conduction studies (NCS),
electromyography (EMG), and myelography].  The
NPTF found no reliability study of these tests. Furthermore,
they did not report on clinical tests used to detect
vascular lesions of the cervical arteries.
The purpose of this systematic review is to update the
findings of the NPTF on the reliability and validity of clinical
tests used to assess the anatomical integrity of the cervical
spine in adults with NAD. This review is the first of a series of
five systematic reviews updating the NPTF on the reliability
and validity of clinical tests and tools used to assess patients
with NAD. Subsequent reviews focus on screening for cervical
spine injuries , measurement of pain and disability , palpation and cervical mobility , and functional tests of the cervical spine.  Together, the purpose of these reviews is to inform the development of a clinical practice
guideline for the clinical assessment of the cervical spine.
This article synthesizes the evidence from three systematic
reviews. The protocols for these reviews were registered
with the International Prospective Register of Systematic
Reviews (PROSPERO). (CRD42016039362,
Our reviews targeted studies of adults (18 years and older)
with NAD grades I–IV including whiplash-associated disorder
(WAD) grades I–IV. We defined NAD according to
the NPTF  (Online Appendix 1) and WAD according to
the Quebec Task Force  (Online Appendix 2).
We included studies evaluating the reliability or validity
of clinical tests for the assessment of anatomical lesions
(musculoskeletal, neurological, or vascular). Clinical tests
used to identify anatomical lesions include procedures
hypothesized to stress isolated anatomical structures. [16, 17] These include:
(1) the evaluation of non-pathological musculoskeletal structures such as joints, muscles, ligaments, and tendons;
(2) nerve root provocation tests used to identify cervical radiculopathy;
(3) neurological examination tests used to assess deep tendon reflexes, pathological reflexes motor strength, and sensory testing; and
(4) hand-held doppler velocimetry to identify vascular lesions.
Eligible studies had to report on the validity or reliability
of clinical tests.
Reliability is the extent to which
repeated measurements of a stable phenomenon by different
people and instruments at different times and places
produce similar results.
Validity is the degree to which the
data measure what they were intended to measure — that is,
the results of a measurement correspond to the true state of
the phenomenon being measured. 
Studies included in our review met the following inclusion
(1) English language;
(2) published in a peer-reviewed journal;
(3) report on the validity or reliability of a clinical test; and
(4) included adults (18 years of age or older) with grades I–IV NAD.
Studies that included individuals
less than 18 years of age were considered for
inclusion if a stratified analysis was conducted and separate
results were reported for adults.
(1) practice guidelines, letters, editorials, commentaries, unpublished manuscripts, dissertations, government reports, books and book chapters, conference proceedings, meeting abstracts, lectures and addresses, consensus development statements, and guideline statements;
(2) systematic and non-systematic reviews, and case studies;
(3) cadaveric or animal studies;
(4) studies solely targeting individuals with grade IV NAD, or serious pathology (e.g., fractures, dislocations, myelopathy, neoplasms, and infection) and systemic diseases; and
(5) studies with sample size less than 20 per group.
Data sources and searches
We developed three search strategies (Online Appendices
3A, 3B, and 3C) with the assistance of a health science
librarian. A second librarian peer-reviewed each search
strategy. We searched MEDLINE, CINAHL, and the
Cochrane Central Register of Controlled Trials (The
Cochrane Library) for: (1) the evaluation of non-pathological
musculoskeletal lesions from January 1, 2005 to
January 1, 2016; (2) the evaluation of cervical radiculopathy
(nerve root provocation and neurological tests)
from January 1, 2006 to June 30, 2016; and (3) clinical
tests identifying vascular lesions from January 1, 1980 to
February 1, 2016. Moreover, we repeated our searches in
SportsDiscus and PubMed for tests evaluating non-pathological
musculoskeletal lesions, and non-neurological
provocation tests and PubMed for tests that aim to identify
vascular lesions. Each search strategy was developed in
MEDLINE through Ovid Technologies Inc., and subsequently
adapted to the other bibliographic databases. We
used a broad search strategy and included terms relevant to
NAD, diagnostic tests, validity, and reliability, including
subject headings specific to each database (e.g., MeSH in
MEDLINE) and free text words.
We used a two-stage screening process to identify eligible
studies. In stage 1, pairs of reviewers (JC_NC; NC_LC;
PM_JW; SdSO_DS; NL_EC; and NL_SdSO) used the
inclusion and exclusion criteria to independently screen titles
and abstracts, and classify articles as relevant, possibly relevant,
or irrelevant. In stage 2, the same reviewers independently
screened possibly relevant studies by reviewing fulltext
manuscripts. In both stages, reviewers met to resolve
disagreements and reach consensus on the eligibility of
studies.Athird independent reviewer resolved disagreements.
A pair of independent reviewers (NC_JW; NL_EC; and
NL_SdSO) critically appraised the methodological quality
of each eligible article. We used the modified Quality
Appraisal Tool for Studies of Diagnostic Reliability
(QAREL)  to appraise the quality of reliability studies
and the modified Quality Assessment of Diagnostic
Accuracy Studies-2 (QUADAS-2)  to evaluate validity
studies. We modified the original QAREL and QUADAS-2
instruments for our review by: (1) adding one question to
assess the clarity of the study objective; (2) adding ‘‘not
applicable’’ options for questions (QAREL items # 3, 4, 5,
6, and 8, QUADAS items # 3.1, 3.2, 3.3, and 3.B); and (3)
adding the Sackett and Haynes classification to the QUADAS-
2.  We contacted authors of eligible studies to
obtain additional information if it was necessary to determine
the internal validity of a study. Reviewers met to
reach consensus on the internal validity of studies. A third
independent reviewer was used to resolve disagreements.
Studies with a low risk of bias (adequate internal
validity) were included in our best evidence synthesis. We
classified each low risk of bias study into one of four
categories according to the nomenclature proposed by
Sackett and Haynes.  This classification system is
useful to determine the level of scrutiny to which a clinical
test/tool has been subjected to determine its clinical utility.
According to this nomenclature, Phase I studies answer the
following question: ‘‘Do test results in patients with the
target disorder differ from those in normal people?’’ Phase
II studies ask: ‘‘Are patients with certain test results more
likely to have the target disorder than patients with other
test results?’’ Phase III studies focus on the following
question: ‘‘Does the test result distinguish patients with and
without the target disorder among patients in whom it is
clinically reasonable to suspect that the disease is present?’’
Finally, Phase IV studies answer the last question: ‘‘Do
patients who undergo this diagnostic test fare better (in
their ultimate health outcomes) than similar patients who
are not tested?’’ Early studies of novel tests provide preliminary
evidence of clinical utility, and Phase III or IV
studies are needed to inform the validity and utility of a test
in clinical practice.
Data extraction and synthesis of results
Authors (NC, NL, and SdSO) extracted data from studies
with low risk of bias and built evidence tables (Tables 1,
2). A second reviewer (JW, EC, and NL) independently
checked extracted data. Due to heterogeneity among
accepted studies, a qualitative synthesis of findings from
studies with a low risk of bias was performed to develop
evidence statements according to principles of the best
evidence synthesis. 
We computed the inter-reviewer agreement [kappa coefficient
(k) with 95% confidence intervals (CI)] for article
screening.  The percentage agreement for critical
appraisal of articles was calculated.
This systematic review was organized and reported based
on the Preferred Reporting Items for Systematic Reviews
and Meta-Analyses (PRISMA) statement  and Statement
for Reporting Studies of Diagnostic Accuracy
We screened 9022 citations (Fig. 1a–c). Eight articles were
critically appraised and all eight had a low risk of bias. [38–40]
The inter-rater agreement for screening of articles was
kappa = 0.40 (95% CI -0.15, 0.94) for non-pathological
musculoskeletal tests and kappa = 1.00 (95% CI 1.00,
1.00) for nerve root provocation tests and neurological
examination. The percentage agreement for article
admissibility during independent critical appraisal was
We contacted the authors of five studies to obtain
additional information [35, 36, 41–43] and two responded. [35, 36]
Three of the eight low risk of bias studies evaluated reliability [33, 37, 38] (Table 1). All three studies reporting on
reliability assessed inter-examiner reliability [33, 37, 38] and one assessed intra-examiner reliability.  Five
studies reported on validity [34–36, 39, 40] (Table 2): three
were classified as Phase II studies [34, 36, 39] and two
were classified as Phase III studies. [35, 40]
The available evidence focussed on the reliability and
validity of the cervical extension–rotation test (two studies) [33, 34], the Spurling’s test (four studies) [36–39], and
neurological examination (two studies). [35, 38] The reliability
of upper limb tension tests was assessed in two
studies. [37, 38] One study assessed the validity of upper
limb neurodynamic tests.  Although they have different
names (upper limb tension test and upper limb neurodynamic
test), both are similar nerve root provocation tests.
No article studying doppler velocimetry for the assessment
of cervical artery vascular lesions in patients with
NAD was found.
Risk of bias
The methodological quality of eligible studies is presented
in Tables 3 and 4. All reliability studies with low risk of
bias used a clearly focused and appropriate research
question and chose samples of subjects and raters that were
representative of the intended population. Furthermore, the
time interval between assessments was stable and all
studies used appropriate statistical measures.
noted the following potential methodological limitations:
(1) o blinding of raters to the results of other examiners (n = 2/3) [33, 37] or unclear (1/3) ;
(2) the order of the examinations was not varied (n = 1/3) ; and
(3) methods of performing and interpreting the test were unclear (n = 1/3). 
All validity studies with low risk of bias avoided inappropriate
exclusion criteria in the patient selection,
described the use of an appropriate reference standard, and
ensured that all patients received the same reference standard.
However, the following limitations were noted:
(1) a consecutive sampling method was not used  or the
sampling method was unclear (n = 2/5) ;
(2) or blinding of the examiners to the reference standard (n = 1/5)  or unclear (n = 1/5) ;
(3) no pre-specified threshold for interpretation of the reference standard (n = 1/5) ;
(4) time interval between the index test and reference standard was not clearly described (n = 1/5) ; and
(5) unclear if all patients were included in the analysis (n = 2/5). [36, 39]
Summary of evidence
Cervical extension–rotation test
Evidence from one
study suggests that the extension–rotation test has adequate
reliability for the detection of pain originating
from the cervical facet joints in patients with NAD. 
The inter-examiner reliability was kappa = 0.92 (95%
CI 0.43, 0.98) for the right side and kappa = 0.93 (95%
CI 0.45, 0.98) for the left side of the neck. The intraexaminer
reliability was kappa = 0.73 (95% CI 0.18,
0.86) for the right side and kappa = 0.75 (95% CI 0.23,
0.88) for the left side. 
Nerve root provocation tests
Evidence from two studies
suggests that for the assessment of patients with persistent
NAD grades I–III, the reliability of the upper limb neurodynamic
test or upper limb tension test, and Spurling’s test
is inadequate and associated with important misclassification
of patients. [37, 38] One study reported that the interrater
reliability of Spurling’s test was kappa = 0.13 (95%
CI -0.19, 0.45) , whereas two studies [37, 38] found
that the inter-examiner reliability of the upper limb neurodynamic
test/upper limb tension test was kappa = 0.36
(95% CI 0.04, 0.68) and kappa = 0.45 (95% CI 0.27,
0.63), respectively. The inter-rater reliability for the median
nerve upper limb tension test was kappa = 0.54 (SE
Evidence from one study
suggests that the inter-examiner reliability of manual
motor testing and dermatomal sensory testing for the
assessment of adults with persistent NAD grades I–III is
likely associated with misclassification of patients. 
Schmid et al. found that the inter-examiner reliability was
kappa = 0.68 (95% CI 0.53, 0.83) for manual motor
testing and kappa = 0.53 (SE 0.13) for dermatomal sensory
Cervical extension–rotation test
Evidence from one
Phase II study suggests that the cervical extension–rotation
test has a sensitivity = 82.7% (95% CI 70.3, 90.6)
and a specificity = 58.9% (95% CI 47.5, 69.5) compared
to comparative medial branch blocks as a reference
standard  for the evaluation of cervical facet jointmediated
pain. When the extension–rotation test was
used in combination with other examination techniques
(e.g., manual spinal examination and/or palpation for
segmental tenderness), the specificity improved [from
58.9% (95% CI 47.5, 69.5) with extension–rotation test
alone to 83.4% (95% CI 73.4, 90.3) with the three
examination techniques combined]; the same applies for
the positive likelihood ratios [from LR+ 2.01 (95% CI
1.49, 2.72) LR–: 0.29 (95% CI 0.16, 0.55) with extension–
rotation test alone to LR+: 4.71 (95% CI 2.75,
8.05); LR–: 0.27 (95% CI 0.16, 0.45) for the three
techniques combined]; however, sensitivity decreased
[from 82.7% (95% CI 70.3, 90.6) to 77.4% (95% CI
64.5, 86.6)] with the three techniques combined (extension–
rotation test, manual spinal examination, and palpation
for segmental tenderness).
Nerve root provocation tests
Two Phase II low risk of
bias studies assessed the validity of Spurling’s test for the
assessment of cervical nerve root compression. [36, 39]
Evidence from one study suggests that the sensitivity and
specificity of Spurling’s test were 0.95 and 0.94, respectively,
when compared to CT findings.  The positive
and negative likelihood ratios were 15.8 and 0.05,
respectively. In the other Phase II study, Anekstein et al.
assessed the validity of six variations of the Spurling’s test  and found that the manoeuvre consisting of extension,
lateral bending, and axial compression of the neck elicited
more arm pain (mean VAS 7/10) and more distally elicited
pain (mean pain = 2.5/3 with 0 = no pain; 1 = neck pain
only; 2 = pain provoked only proximal to the elbow, and
3 = pain provoked distal to the elbow) compared to control
In one Phase III study of patients with grades II–III NAD,
the sensitivity and specificity of the upper limb neurodynamic
test used to assess cervical nerve root compression
were 0.97 (95% CI 0.85, 0.99) and 0.69 (95% CI 0.44, 0.86)
when compared to MRI findings, patient history, and clinical
examination.  The positive and negative predictive values
were 0.87 (95% CI 0.73, 0.96) and 0.92 (95% CI 0.61,
1.00), respectively. The positive and negative likelihood
ratios were 3.13 and 0.04, respectively.
Evidence from one Phase III
study suggests that the sensitivity and specificity of a
neurological examination (i.e., manual muscle testing,
dermatomal sensory testing, deep tendon reflexes, and
pathological reflex testing) were 0.83 (95% CI 0.55, 0.95)
and 0.28 (95% CI 0.15, 0.46), respectively, when compared
to needle EMG.  The positive and negative predictive
values were 0.32 and 0.80, respectively. The positive and
negative likelihood ratios were 1.15 (95% CI 0.82, 1.61)
and 0.60 (95% CI 0.15, 2.44), respectively.
We reviewed the evidence on the reliability and validity
of clinical tests for the assessment of the anatomical
integrity of the cervical spine in adults with NAD grades
I–IV. Very little evidence is available to justify the use of
these clinical tests. We found preliminary evidence suggesting
that the extension–rotation test may be valid to
rule out pain originating from the cervical facet joints in
adults with persistent NAD. However, this is based on
Phase II evidence and these results need to be tested in a
Phase III study. Similarly, we found preliminary evidence
suggesting that the Spurling’s test may be valid to rule
out radiculopathy in patients with persistent NAD III.
Again, this evidence is from a Phase II study; therefore,
diagnostic accuracy of the Spurling’s test needs to be
tested in a Phase III study.
Our review suggests that the upper limb neurodynamic
test/upper limb tension may be valid to rule out cervical
radiculopathy. Finally, the execution of manual motor
muscle testing and dermatomal sensory testing is associated
with important misclassification and the neurological
examination (including manual muscle testing, sensory
dermatomal testing, deep tendon reflexes, and pathological
reflex testing) may be sensitive, but has poor
Update of findings from the NPTF
Our review expands on the findings of the NPTF. In
their 2008 systematic review, the NPTF did not identify
studies on the validity of tests for the assessment of nonpathological
musculoskeletal lesions. Despite their call
for further research, our review found only two highquality
studies on this topic. Our update of the NTPF
found limited evidence suggesting that the cervical
extension–rotation test may be useful for the identification
of pain originating from the cervical facet joint in
adults with persistent NAD grades I–II. Our review
supports the findings of the NPTF concerning the
validity of nerve root provocation tests. Specifically, we
found evidence consistent with the conclusions of the
NPTF that the Spurling’s test and the upper limb neurodynamic
test/upper limb tension test may be valid for
the evaluation of nerve root compression in adults with
persistent NAD grades I–III.  However, it is
important to note that the reliability of the Spurling’s
and upper limb neurodynamic test/upper limb tension
tests is not adequate. Therefore, its clinical utility could
be improved. We found no evidence on the assessment
of cervical artery patency using doppler velocimetry in
patients with NAD.
Strengths and limitations
Our review has strengths. First, our search strategy was
reviewed by a second librarian. Second, we defined a
specific set of inclusion and exclusion criteria to identify
all possibly relevant citations from the searched literature.
Third, two independent reviewers screened and
critically appraised all articles. Fourth, we used a wellaccepted
and valid set of criteria to critically appraise
studies. [26, 27] Finally, our best evidence synthesis
minimizes bias by synthesizing evidence from low risk
of bias studies. 
Our review also has limitations. First, we restricted
our search to studies published in the English language;
therefore, we may have omitted relevant studies. However,
previous systematic reviews have found that this
restriction does not lead to a bias. [44–48] Second,
critical appraisal requires scientific judgment that may
vary among reviewers. This potential bias was minimized
by training reviewers to use a standardized critical
appraisal tool and using a consensus process among
reviewers to reach decisions. Finally, like all systematic
reviews, our search may not have included all relevant
studies. The inter-rater agreement for screening of titles
and abstracts could have been higher. However, disagreements
were resolved by a consensus discussion
between two reviewers before a final decision on its
eligibility was made.
Most of the evidence on the assessment of the anatomical
integrity of the cervical spine is preliminary. Therefore,
few clinical tests can be used to assess adults with NAD.
Based on preliminary evidence, clinicians may consider
using the extension–rotation test, neurological examination
(manual motor testing, dermatomal sensory testing, deep
tendon reflexes, and pathological reflex testing), Spurling’s
test, and upper limb neurodynamic tests. However, clinicians
should be aware that the validity of these tests is not
firmly established and could lead to misdiagnosis. The
clinical utility of these tests could be increased with a
proper training, leading to reduced misclassification error
and improved reliability.
The current evidence suggests that clinicians must
conduct a thorough clinical history and investigate red flags
to rule out serious pathology. This is a clinician’s most
important responsibility. Clinical tests that do not have
evidence of reliability and validity can lead to misdiagnosis
and should not be used in clinical practice; therefore, they
should not be used until their validity has been
We found limited evidence to support the use of clinical
tests used to evaluate the anatomical integrity of the cervical
spine. The evidence is at best preliminary for a few
tests. Clinicians have very few valid and reliable clinical
tests to evaluate patients and arrive at a meaningful diagnosis.
This emphasizes the importance of a thorough
clinical history to exclude red flags and avoid misdiagnosis
of patients with neck pain. Future research needs to address
this important gap.
The authors acknowledge and thank Mrs.
Sophie Despeyroux, librarian at the Haute Autorite´ de Sante´, for her
suggestions and review of the search strategy. This research was
undertaken, in part, thanks to funding and supervision from the
Canada Research Chairs program to Dr. Pierre Cote, Canada Research
Chair in Disability Prevention and Rehabilitation at the University of
Ontario Institute of Technology.
This study was funded by the Institut Franco-Europe´en de
Chiropraxie, the Association Franc¸aise de Chiropraxie, and the Fondation
de recherche en chiropraxie in France. None of these associations
were involved in the collection of data, data analysis,
interpretation of data, or drafting of the manuscript.
Conflict of interest
The authors declare that they have no conflict of interest.
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