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Original article

Manual physical assessment of spinal segmental motion:Intent and validity

J. Haxby Abbott a,*, Timothy W. Flynn b, Julie M. Fritz c, Wayne A. Hing d,Duncan Reid e, Julie M. Whitman b

a Centre for Physiotherapy Research, School of Physiotherapy, University of Otago, PO Box 56, Dunedin, New Zealandb Department of Physical Therapy, Regis University, Denver, CO, USA

c Division of Physical Therapy, University of Utah, Salt Lake City, UT, USAd School of Physiotherapy, Auckland University of Technology, Auckland, New Zealand

e Division of Rehabilitation and Occupation Studies, Auckland University of Technology, Auckland, New Zealand

Received 19 March 2007; received in revised form 10 August 2007; accepted 13 September 2007

Abstract

Validity of a clinical test can be defined as the extent to which the test actually assesses what it is intended to assess. In order toinvestigate the validity of manual physical assessment of the spine, it is therefore essential to establish what physical therapists intendto assess when they are applying these tests.

The aims of this study were to (1) establish what manual physical therapists are intending to assess while applying passive in-tervertebral motion tests; and (2) examine the face validity and content validity for manual physical assessment of the spine.

We surveyed 1502 members of the national manual physical therapist organisations of New Zealand and the United States ofAmerica using a web-based survey instrument. Sixty-six percent of 466 respondents believed passive accessory intervertebral motion(PAIVM) tests were valid for assessing quantity of segmental motion, and 76% believed passive physiologic intervertebral motion(PPIVM) tests were valid for assessing quantity of segmental motion. Ninety-eight percent of manual physical therapists base treat-ment decisions at least in part on the results of segmental motion tests. Quality of resistance to passive segmental motion was con-sidered of greater importance than quantity of kinematic motion during PAIVM tests, while the quality of complex kinematicmotion was considered of greater importance than quantity of displacement kinematics during PPIVM tests.

Manual physical therapists accept the face validity of manual physical assessment of spinal segmental motion to a great extent,however a minority voice scepticism. Content validity is dominated by concepts of segmental kinematics and the forceedisplacementrelationship. Intent of assessment does, however, vary widely between therapists. These data will inform the design of concurrentvalidity studies. Further work is recommended to increase consistency of intent, methodology and terminology in manual physicalassessment of the spine.! 2007 Elsevier Ltd. All rights reserved.

Keywords: Physical therapy techniques; Manual therapies

1. Introduction

Expert clinicians believe that lumbar spinal segmental(intervertebral) motion is an important factor in low

back pain (LBP) and that it can be assessed using phys-ical examination procedures (Binkley et al., 1993). Someform of physical assessment of spinal motion is integralto almost all classification systems used by expert mus-culoskeletal physical therapists (PTs) to diagnose sub-groups within non-specific spinal disorders (Paris,1985; Nyberg, 1993; Delitto et al., 1995; Riddle, 1998;

* Corresponding author. Tel.: !64 3 479 5133; fax: !64 3 479 8414.E-mail address: haxby.abbott@otago.ac.nz (J.H. Abbott).

1356-689X/$ - see front matter ! 2007 Elsevier Ltd. All rights reserved.doi:10.1016/j.math.2007.09.011

Available online at www.sciencedirect.com

Manual Therapy 14 (2009) 36e44

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Van Dillen et al., 1998; Laslett and van Wijmen, 1999;Petersen et al., 1999; Flynn et al., 2002; Cook et al.,2006). Two common manual physical examination pro-cedures used by PTs to detect spinal segmental mobilityare passive accessory intervertebral motion tests(PAIVMs) and passive physiological intervertebral mo-tion tests (PPIVMs) (Abbott et al., 2005).

The face validity of these manual physical examina-tion tests for detecting spinal segmental mobility is notuniversally accepted. The ‘content universe’ of proper-ties of motion the assessor is expected to assess [i.e. allof what is entailed in the entity the test is intended tomeasure, and the relative importance of each componentof that entity (Portney and Watkins, 1993)] is notknown. The literature contains a very wide range of de-scriptors of what may be felt with manual segmentalmobility assessment (Maher et al., 1998; Cook et al.,2006), although two studies suggest that the key con-cepts are quantity of motion and the forceedisplace-ment relationship (Binkley et al., 1993; Maher et al.,1998). Beyond this, little is known about the relative im-portance placed on the quantities of motion that may beassessed, or the various characteristics that may beperceived.

The aim of this study was to investigate the face val-idity and content validity of manual assessment of spinalsegmental motion. We aimed to examine: (1) the extentto which manual PTs accept the face validity of twocommon manual physical assessment procedures,PAIVMs and PPIVMs, for detecting spinal segmentalmotion; and (2) the relative importance of each compo-nent of the core ‘content universe’ for these tests.

2. Methods

The target population for this study was members ofthe New Zealand Manipulative Physiotherapists Associ-ation (NZMPA) and the American Academy of Ortho-paedic Manual Physical Therapists (AAOMPT). Weincluded all PTs who: (a) were financial members of

these organisations in December 2005; and (b) had anactive email address on file with the organisation. Thisprotocol was reviewed by the Institutional ReviewBoard of Regis University, and was designated IRBExempt.

Development of the survey instrument was ap-proached in three phases. The principal investigator(JHA) developed version 1 as part of earlier research(Abbott, 2005). Pilot data from that research informedversion 2, which was further developed through consul-tation with the co-investigators and colleagues. Wethen designed version 3 using WebSurveyor"

(www.websurveyor.com), and pilot-tested the surveyinstrument on a small sample of manual PTs (n"15).Based on feedback from the pilot test, we rewordedquestions and responses where necessary for the finalversion.

We populated the WebSurveyor database with the listof email addresses provided by NZMPA andAAOMPT. The WebSurveyor" program sent an emailinvitation to eligible PTs. Respondents submitted com-pleted surveys via WebSurveyor", which logged the sub-mission, added the responses to the results database,and withheld further reminder notices to the email ad-dress of the respondent. Non-respondents were emailedthree reminder notices at 1-week intervals.

Our examination of the extent of face validity wasbased on three questions. In the first question, partic-ipants were asked to choose (on a Likert scale) howaccurate they believe each of the physical assessmentprocedures (PAIVMs and PPIVMs) are for estimatingthe quantity of movement present at a lumbar seg-ment. In the second question, participants were askedif they believe that it is possible, from the clinical ex-amination, to recognise restricted or excessive lumbarsegmental motion. The third question relied on the as-sumption that participants demonstrated acceptance offace validity if they reported that, in clinical practice,they select di!erent treatment options for patientswith LBP on the basis of lumbar segmental motionfindings.

Table 1Responses available to respondents for survey questions on intent of manual physical assessment and basis for comparative decisions

Responses available for ranking: intent of manual physical assessment Responses available for ranking: basis for comparative decisions

# Position of the vertebrae, or normality of the position of vertebraeduring motion

# Quantity of angle of spinal bending# Quantity of translation of the vertebrae# Quality of resistance (e.g. greater or lesser sti!ness, force-

displacement relationship)# Quality of end-feel or tissue-feel (e.g. capsule, disc, muscle,

ligament, bony, cartilage)# Quality of the motion during the movement, or normality of the

path of vertebral motion# The patient’s pain response (verbal or observed)# Other

# The mobility you expect for that segmental level, taking intoaccount the patient’s age and/or body type

# The mobility you expect for that segmental level, compared to yourexperience of assessing the same segmental level in other patientsand normal individuals

# The mobility you expect for that segmental level, compared toother segments above and below

# The patient’s pain response (verbal or observed) to the procedure# Other

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We then examined the two principal aspects of contentvalidity: the ‘content universe’ and the relative order ofimportance of each component of that content universe(Portney and Watkins, 1993). We identified, from themanual PT literature, key properties of motion withinthe content universe related to intent of manual segmen-tal motion assessment and incorporated these as availableresponses to survey questions (Table 1). To establish thebasis on which PTs make comparative decisions regard-ing these motion properties, we asked participants torank the choices available from most important to leastimportant. Respondents could leave blank any choicethat did not represent their modus operandi.

We captured other components of the content uni-verse, and other bases for decision-making, by includingan ‘‘other’’ response. Respondents choosing ‘‘other’’were invited to submit a free-text response. We also in-cluded a request for further comments at the end of thesurvey instrument. These were analysed qualitatively bytwo investigators (WH, DR), and independently by an-other investigator (JHA) using Editing Analysis Styleprinciples (Crabtree and Miller, 1992), until all majorthemes were identified. The minimum number of like re-sponses necessary to constitute a theme was set at 5%.A hierarchy of themes was derived from the data:meta-themes, themes, and (where necessary) sub-themes. The final themes were subsequently agreed byconsensus between the three investigators.

Descriptive statistics (number, percent) were used tosummarise the data. For ranked responses, we countedthe frequency each response was ranked at each rankinglevel, and present only the frequency they were rankedby respondents as most important (#1) and secondmost important (#2). We calculated the frequency andproportion of free-text responses in each theme whicharose in the qualitative analysis.

3. Results

Four hundred sixty-six (31%) of 1502 eligible PTs re-sponded. Characteristics of the participants are de-scribed in Table 2.

The majority of respondents (65.9%; 95% confidenceinterval 61.5%, 70.0%) believed that central postero-an-terior PAIVMs are ‘somewhat accurate’ or ‘very accu-rate’ for estimating the quantity of movement presentat a lumbar segment (for example identifying restricted,normal, excessive movement) (Table 3). A still higherproportion (76.2%; 72.1%, 79.8%) believe that PPIVMsare ‘somewhat accurate’ or ‘very accurate’ for estimatingthe quantity of movement present at a lumbar segment(Table 3). Most respondents (97.6%; 95.8%, 98.6%) re-port that they select di!erent treatment options for pa-tients with LBP at least partly on the basis of lumbarsegmental motion findings.

When asked to consider what they are intending toassess when performing central postero-anteriorPAIVMs, the greatest proportion of respondents rankedthe patient’s pain response (verbal or observed) as most

Table 2Characteristics of respondents

RespondentsTotal 466/1502 (31%)

Country of PT practiceUSA 395 (86%)NZ 64 (14%)Other 2 (0.2%)

Direct patient care>30 h/week 280 (61%)21e30 h/week 65 (14%)20 or less hours/week 115 (25%)

Low back pain patients>30% of caseload 280 (61%)10e30% of caseload 154 (34%)<10% of caseload 25 (5%)

Entry level PT degreeCertificate/diploma/other 66 (14%)Bachelors 212 (46%)Masters 156 (34%)Clinical doctorate (DPT) 27 (6%)

Highest earned degreeCertificate/diploma/other 71 (17%)Bachelors 100 (22%)Masters 170 (37%)Clinical doctorate 81 (18%)Research doctorate 38 (8%)

Professional designationsa

ABPTS certified (e.g. OCS) 188 (48%)MNZMPA or FAAOMPT 165 (41%)Neither 152 (38%)

PT, physical therapy or physiotherapy; USA,United States of America;NZ, New Zealand; DPT, Doctor of Physical Therapy degree; ABPTS,American Board of Physical Therapy Specialties; OCS, OrthopaedicCertified Specialist; NZMPA, fully qualified Member of the New Zea-land Manipulative Physiotherapists Association; FAAOMPT, Fellowof the American Academy of Orthopaedic Manual Physical Therapists.a Percentages exceed 100% because respondents may be in more

than one category.

Table 3Responses to the questions ‘‘Indicate how accurate you believe [centralP-A PAIVMs/PPIVMs] are for estimating the quantity of movementpresent at a lumbar segment (for example identifying restricted,normal, excessive movement)’’

PAIVMs: number(%)a

PPIVMs: number(%)b

Not at all accurate 42 (9.2%) 20 (4.4%)Somewhat inaccurate 114 (24.9%) 89 (19.4%)Somewhat accurate 250 (54.7%) 279 (60.9%)Very accurate 51 (11.2%) 70 (15.3%)

PAIVMs, passive accessory intervertebral motion tests; PPIVMs,passive physiological intervertebral.a Percent of valid data, 9 (1.9%) missing.b Percent of valid data, 8 (1.7%) missing.

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important (31.8% ranked this response #1; 18.8%ranked it #2). Quality of resistance (e.g. greater or lessersti!ness, forceedisplacement relationship) was the nextmost highly ranked (28.8 #1; 28.8 #2), followed byquantity of translation of the vertebrae (11.5; 13.7). Fur-ther results are presented in Fig. 1.

When asked to consider what they intend to assesswhen they performPPIVMs, quality of themotion duringthe movement (or normality of the path of vertebral mo-tion) was ranked most important by respondents (29.7%ranked this response #1; 24.8% ranked it #2). Quantity ofangle of spinal bending (e.g. flexion, extension, or side-bending) was the next most highly ranked (19.5 #1; 16.6#2), followed by position of the vertebrae during motion(13.7; 9.8). Further results are presented in Fig. 2.

How respondents judge spinal mobility during pas-sive intervertebral motion assessment procedures, is pre-sented in Fig. 3.

The free-text responses o!ered by participants fellinto two meta-themes: justification and clarification.The themes revealed for PAIVMs and PPIVMs werenot dissimilar, so were collapsed into common themes.Results from the 73 free-text responses o!ered are listedin Table 4. Regarding what manual PTs intend to assessusing manual tests of segmental motion, comments sug-gested that interaction between properties (or domains)are assessed by some respondents:

‘‘A general sense of movement quality related to qualitydeterminants such as palpable resistance, muscle spasm,and related to other patient psycho-physiologicalresponses.’’

‘‘The pain-range behavior which I’ll define as the wherein range is the pt’s concordant sign reproduced and withhow much force.’’

Several respondents were sceptical about the validityof manual physical assessment of spinal segmentalmotion:

‘‘I do not use this technique in general. There is veryweak EBP.’’

‘‘Very rarely use them. The literature indicates they areof little value with poor reliability to determine a level letalone anything else of use.’’

Other

Pain response

Quality of motion path

Quality of end-feel

Quality of resistance

Quantity of translation

Quantity of angle

Position of vertebra

Ranked #1 , #2Property

11. 5

28. 8

9.4

31. 8

11. 5

18. 8

28. 8

24. 1

9.7

13. 7

4.6

Fig. 1. Responses to the question ‘‘Consider what you are intending toassess when you perform central P-A PAIVMs. Using the drop-downboxes, please rate the following choices in rank order, from most im-portant to least important.’’ Data represent the proportion (in percent)of manual physical therapists who ranked each response as of thegreatest importance (dark red bar) and second greatest importance(light blue bar) during assessment of spinal segmental motion. Fourhundred and fifty-nine (98.5% of) respondents gave at least 1 rankedresponse, 452 (97% of) respondents gave 2 or more ranked responses.Data were missing for 7 (1.5%) participants.

Other

Pain response

Quality of motion path

Quality of end-feel

Quality of resistance

Quantity of translation

Quantity of angle

Position of vertebra

Ranked #1, #2Property

11. 1

6.7

5.3

12.0

13. 7

29. 7

7.3

17.3

13. 2

16.6

9.8

24. 8

10.7

19. 5

Fig. 2. Responses to the question ‘‘Consider what you are intending toassess when you perform central PPIVMs. Using the drop-downboxes, please rate the following choices in rank order, from most im-portant to least important.’’ Data represent the proportion (in percent)of manual physical therapists who ranked each response as of thegreatest importance (dark red bar) and second greatest importance(light blue bar) during assessment of spinal segmental motion. Fourhundred and fifty-one (96.8% of) respondents gave at least 1 rankedresponse, 440 (94.4% of) respondents gave 2 or more ranked re-sponses. Data were missing for 15 (3.2%) participants.

#1

Other

Pain response

Segments above & below withinthe same patient

That segment allevel cf. otherpatients & normals

That segmental level consideringage & body type

Ranked , #2Judgement made by mobilityexpected compared to:

14.4 35.1

13.7 29.7

60.6 21.4

8.9 12.8

2.4

Fig. 3. Responses to the question ‘‘Consider how you judge spinal mo-bility. Do you base your judgments on any of the following? Using thedrop-down boxes, please rate the following choices in rank order, frommost important to least important.’’ Data represent the proportion (inpercent) of manual physical therapists who ranked each response as ofthe greatest importance (dark red bar) and second greatest importance(light blue bar) during assessment of spinal segmental motion. Fourhundred and fifty-nine (98.5% of) respondents gave at least 2 rankedresponses. Data were missing for seven (1.5%) participants.

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Regarding how manual PTs make comparative judg-ments about the motion of a spinal segment, one maintheme was identified from the 37 free-text responses of-fered by respondents (Table 5). Respondents emphas-ised the importance of the patient’s history and otherclinical findings, indicating that the influence of pre-test probability is taken into account:

‘‘Expected mobility for that segment based on the pa-tient’s history of injury and course of symptom progres-sion/regression.’’

‘‘Patients response to active movement, observationskills patterns of movement and postural influences,i.e. descrepencies [sic] in anatomy, weak muscles etc.’’

Comments o!ered in the final free-text question revealedthree main themes (Table 6). Among the 144 free-text re-sponses, many respondents commented that manualtests of segmental motion are but a part of a more com-prehensive set of data collected to inform clinical deci-sion-making:

‘‘PPIVM and PAIVM must be used along with othertests to rule in or out diagnostic hypotheses that wereformed from the history and subjective report. Onetest does not stand alone.’’

The theme of scepticism regarding the reliability andvalidity of manual tests of segmental motion continued:

‘‘.I believe the literature to date does not support thisapproach.’’

although some acknowledged evidence supporting theirvalid use:

‘‘I rarely use PPIVMs now. Unreliable and invalid. I usethem only to identify the anatomical [sic] segment once Ihave chosen to perform a manipulative procedure. I usePAIVMs primarily for pain response (provocation orabolition). I now consider (on the basis of current evi-dence) that PAIVMs may have value in a composite of

clinical findings for identifying patients most likely to re-spond to manipulation (Flynn, Childs, Fritz papers).’’

‘‘As noted in the lit [literature] the reliability of PPIVM’sand PAIVM’s is poor however combined with othersubjective and objective data we can subgroup LBP pa-tients and apply CPR’s [clinical prediction rules].’’

4. Discussion

Our data indicate that most (66e76%) manual PT re-spondents have faith in the accuracy of manual segmen-tal mobility assessment procedures for detectingquantity of spinal segmental motion. Few (5e9%) ex-pressed scepticism, or rated the procedures as ‘‘not atall accurate’’. The overwhelming majority (98%) basepatient treatment choices at least partly on the basis oflumbar segmental motion assessment findings. These

Table 4Themes identified from ‘other’ responses to the questions ‘‘Consider what you are intending to assess when you preform.’’ PAIVMs and PPIVMs

Themea Number (%)b Examples from the data

Interaction of domains 12 (16%) ‘‘Pain response combined with quantity of motion’’‘‘Relationship of pain and resistance’’‘‘Here I am looking for di!erent things if the patient’s condition is acute or more chronic’’

Muscle-related 7 (10%) ‘‘Influence of muscle length on vertebral movement’’‘‘Paraspinal muscle reactivity or reaction’’

Symptom-related 5 (7%) ‘‘Ability to reproduce patient’s symptoms’’Scepticism 4 (5%) ‘‘I don’t use this technique in general. There is very weak EBP’’

‘‘The literature indicates they are of little value with poor reliability.’’

PAIVMs, passive accessory intervertebral motion tests; PPIVMs, passive physiological intervertebral motion tests.a Two other common themes (movement-related and position by palpation) are not listed as they replicate responses available in the survey

instrument.b Number (%) of 73 comments represented by theme. Percentages do not sum to 100, because some comments either could not be classified by

theme, or represented responses available in the survey questions (Table 1).

Table 5Themes identified from ‘other’ responses to the question ‘‘Considerhow you judge spinal mobility. Do you base your judgments on.’’

Theme Number (%)a Examples from the data

Taking otherhistory and physicalfindings into account(sum of subthemes)b

22 (59%) ‘‘Based on medical/surgicalhistory and whatpatient presents in hissubjective history/complaints’’‘‘Patient history/descriptionof activities/positions thatproduce the pain/catching;irritability of presentation’’‘‘Range of motiontesting; observing qualityand quantity of motion’’

a Number (%) of 37 comments represented by theme. Percentages donot sum to 100, because some comments could not be classified bytheme, or represented responses available in the survey questions(Table 1).b Subthemes identified were: History examination; Symptoms

(including reproduction of); Other physical examination items.

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findings are consistent with previous research indicatingthat segmental motion is an important clinical finding inthe examination and diagnosis of patients with spinalpain (Binkley et al., 1993; Cook et al., 2005a, 2006),and PTs are confident in diagnosing segmental motiondisorders (Cook et al., 2005b). Our data concur withCook and colleagues (2005b), who found that over70% of manual PTs in their Dephi study ‘often’ or‘very often’ use palpable segmental mobility abnormali-ties in the diagnosis of spinal instability (Cook et al.,2005b). We therefore conclude that acceptance of theface validity of manual segmental mobility assessmentprocedures is strong among manual PTs.

Our data indicate that, overall, quantity of motionand quality of the forceedisplacement relationshipwere the dominant concepts within the content universeof spinal segmental motion, concurring with earlier re-search (Binkley et al., 1993; Maher et al., 1998; Cooket al., 2006). Few respondents ranked ‘other’ propertiesof segmental motion as highly important, for eitherPAIVM or PPIVM testing, which supports the viewthat the content universe of what is intended to be as-sessed during these manual tests was adequately repre-sented by the responses available (see Table 1). Withinthese responses, however, considerable variability wasseen in the data.

Patients’ pain response to PAIVM testing was ratedof highest importance by more respondents (32%)than rated any of the motion properties highest, whichis consistent with research indicating that these assess-ment procedures are accurate for the detection of a pain-ful segment (Phillips and Twomey, 1996). A largeproportion of respondents (58%: equally split between#1 and #2 rankings) intend to assess the quality of resis-tance to movement (i.e. greater or lesser sti!ness; theforce-displacement relationship) during PAIVM testing,as found by (Maher et al., 1998), and supported by

experimental research using a proxy criterion standardfor sti!ness (Chiradejnant et al., 2003a).

A wide variety of other motion properties wereranked highly by respondents. Manual PTs also com-monly use PAIVM tests to assess quantity of translationand the quality of the ‘end-feel’ of segmental motion.Few studies have measured sagittal translation motion,however, those that have report that the magnitude ofmotion is small (Lee and Evans, 2000), may not be man-ually perceptible (Lee and Evans, 1997), and may be inthe opposite direction to that which some manual PTtheories might predict. Posterior translation seems to oc-cur because of the spine behaving like a flexible beamundergoing three-point bending, rather than anteriortranslation of one vertebra on the neighbouring vertebrabelow (Lee and Evans, 1997). Although these in vitroand in vivo laboratory studies findings dispute the facevalidity of manual segmental mobility assessment, tworecent criterion-related validity studies independentlyconcluded that PAIVMs may possess concurrent valid-ity for detecting excessive sagittal translation (Abbottet al., 2005; Fritz et al., 2005a). Despite di!ering meth-odology and populations, their results were highly con-sistent, which provides rigorous independent validation(Abbott, 2007). Although in one of the studies (Fritzet al., 2005a) the likelihood ratio for a positive test(LR!) was not statistically significant, it appears likelythat this may be due to type 2 error as the other study(Abbott et al., 2005) with a larger sample size found al-most exactly the same LR! estimate, and was statisti-cally significant. Similarly, in one of the studies(Abbott et al., 2005) the likelihood ratio for a negativetest (LR-) was not statistically significant, however,again this is likely to be type 2 error, as the study withthe higher prevalence of excessive sagittal translation(Fritz et al., 2005a) found a highly comparable LR-estimate and was statistically significant. The magnitude

Table 6Themes identified from responses to the question ‘‘Would you like to comment on any aspect of the use of PAIVM or PPIVM assessments for theexamination of the spine?’’

Theme Number (%)a Examples from the data

Part of a multi-factorial process 49 (34%) ‘‘I view PPIVM and PAIVM as part of a comprehensive examination process inorthopedic [sic] physical therapy. Findings are taken within the context of allphysical examination findings, as well as the subjective portion of the patientexamination’’

I do it di!erently 14 (10%) ‘‘I perform PAIVMs superior and inferior directions to access facet restrictions, notin a PeA direction’’‘‘Generally don’t use them due to McKenzie training’’

Scepticism 13 (9%) ‘‘Questionable interrater reliability’’‘‘I rarely use PPIVMs now. Unreliable and invalid’’

Experience is necessary to use these tests 10 (7%) ‘‘I also think that the ability of a therapist to consistently use these tools increasesthere [sic] reliability and validity’’

Essential to the clinical examination 7 (5%) ‘‘A spinal evaluation is not complete unless PPIVM and/or PAIVM are performed!’’

PAIVM, passive accessory intervertebral motion; PPIVM, passive physiological intervertebral motion.a Number (%) of 144 comments represented by theme. Percentages do not sum to 100, because some comments could not be classified by theme, or

represented responses available in the survey questions (Table 1).

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of these associations is, however, small, indicating that:(a) a single clinical examination procedure in isolationhas only weak diagnostic value; and possibly also that:(b) the kinematic properties measured as a criterion inthese studies may not adequately represent the contentuniverse of what manual PTs are assessing while per-forming these examination procedures.

Research indicates that sagittal rotation occurs dur-ing PAIVM testing (Powers et al., 2003; Kulig et al.,2004, 2007; Beneck et al., 2005; Lee et al., 2005), al-though they are noted to be small, leading some authorsto speculate that accurate detection by manual meanswould unlikely (Lee and Evans, 1997). Lee and Evans(1997) also note that the vertebrae rotate and translatesimultaneously, and suggest it unlikely the assessingtherapist would be able to discriminate the componentmovement properties. Limited motion will certainly beof a small magnitude, and it is unclear whether excessivesagittal rotation is an important factor associated withLBP (Abbott et al., 2005, 2006). Our data, however, sug-gest that very few manual PTs intend to assess sagittalrotation during PAIVM testing, which diminishes theexternal validity of such speculation.

There have been few technical studies of PPIVMs,however, excessive sagittal translation motion hasbeen shown to be more readily detected by flexioneextension in the side-lying position than by standingflexioneextension (Wood et al., 1994), and there is pre-liminary evidence that PPIVMs performed in side-lyingmay have moderate validity for detecting excessive sag-ittal translation, however, further research must bedone to confirm these findings (Abbott and Mercer,2003; Abbott et al., 2006). No studies have yet exam-ined complex kinematics during spinal segmental mo-bility testing.

The quality of the path of motion perceived by the as-sessor during PPIVM testing was ranked of highest im-portance by respondents, both in terms of #1 ratingsand the aggregate of #1 and #2 ratings. This indicatesthat complex kinematics were considered more impor-tant than simple displacement kinematics (such as quan-tity of angledsecond most highly rateddand quantityof translation). This proposition will pose technical dif-ficulties to researchers choosing a reference standard forassessing the criterion-related validity of PPIVM testing,however, emerging evidence both supports the relativeimportance of complex kinematics over simple displace-ment kinematics in patients with LBP, and o!ers techni-cal solutions to measuring it (Abbott, 2005; McCaneet al., 2006; Teyhen et al., 2007).

The data we have provided on manual PTs intent willinform researchers in the design and interpretation ofcriterion-related concurrent validity studies, helping toensure a match between intent and an appropriate refer-ence standard. The present data indicate that manualPTs’ intent of assessment encompasses more than one

domain, therefore when interpreting the results of crite-rion-related concurrent validity studies readers shouldtake this fact into account. Criterion-related validitystudies may underestimate validity if they examineonly one domain, such as sagittal translation, withoutexamining other important domains, such as sti!ness.Estimates of the actual validity must take into accountcriterion-related validity of the important biomechanicaldomains therapists intend to assess concurrently (suchas displacement, aberrant path of motion, and sti!ness)as well as predictive validity.

With little evidence of the validity of manual physicalassessment procedures, our data suggest that somemanual PTs may have turned to research investigatingtheir reliability as a proxy measure to support or refuteface validity. We suggest that it is a poor choice ofproxy for three principal reasons. Firstly, we refer thereader to (Wainner, 2003) for enlightening data and ar-gument on why low reliability may not preclude diag-nostic or prognostic utility, although it must be notedthat the data Wainner presents are single estimatesfrom di!erent studies, indicating that further researchis required to adequately support the theory he presents.Secondly, the threshold for how reliable a test must bein order to be useful depends on several factors, notleast being the consequences of an erroneous result(Rothstein, 2001; Wainner, 2003). And thirdly, useful-ness (i.e. validity) is a more important property ofa test than reliability, but is generally more di"cult tostudy (Rothstein, 2001). There is growing evidencethat manual physical assessment procedures are useful,in that they demonstrate predictive validity both for thepurpose of making treatment decisions and for out-come, particularly when combined with other factorsin a multivariate decision rule (Chiradejnant et al.,2002; Flynn et al., 2002; Fritz et al., 2003, 2004,2005b; Childs et al., 2004; Hicks et al., 2005), althoughnot all studies support these propositions (Haas et al.,2003; Chiradejnant et al., 2003b). Our data, indicatingthat the majority of manual PTs believe manual physi-cal assessment procedures are moderately (somewhat)accurate, and overwhelmingly use the results of thoseprocedures to make treatment decisions, indicates thatmanual PTs practice is consistent with the available ev-idence on usefulness. Our data also indicate that man-ual PTs recognise that the validity of these tests is notstrong enough to stand alone, so use them in conjunc-tion with other observations, tests and measures.

A plausible explanation for poor reliability, accord-ing to Maher et al. (1998), may be that therapists’knowledge of what biomechanical properties they areable to assess, and what properties are important inLBP, is inadequate. Terminology is inconsistent and of-ten jargon-filled (Maher et al., 1998). We concur withthis view, and believe that this inadequate knowledgebase and terminology may explain the considerable

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variation in the data from the respondents to this study.Consistent methodology and terminology grounded insound biomechanical and clinical evidence may facilitatecommunication between teacher and student; therapistand patient; clinician and researcher; and between mem-bers of the interdisciplinary health-care team.

Conclusions drawn from these results must take intoaccount the strengths and limitations of the data. Thedata represent a large sample of clinically active man-ual physical therapists across two countries, suggestinginternational generalisability of the results, however,the small sample from New Zealand (due to its smallerpopulation) does not permit subgroup comparisons.Respondent bias may have inflated our estimates offace validity, because it is likely the 31% of eligiblemanual PTs who responded have a greater interestin, and therefore belief in, the validity of the manualphysical assessment techniques in question. As wewere not able to capture a sample of non-respondents,we cannot discount the possibility that the responses ofparticipants may di!er from those of non-participatingmanual PTs. However, the possibility of respondentbias is mitigated by evidence of relatively high levelsof scepticism regarding these assessment techniques.The use of prepared responses that respondents wereasked to rank in order of importance may have ledto bias, however, this is mitigated by the fact that re-spondents did not o!er a large number of free-text re-sponses, and very few of these were ranked highly byrespondents.

5. Conclusions

Manual physical therapists attribute moderate tostrong face validity to manual passive assessment tech-niques, both for assessing spinal segmental motion andas a basis for determining what type of intervention isindicated. There remains some scepticism regarding thevalidity of manual passive assessment techniques, de-spite growing evidence of their concurrent and predic-tive validity. This scepticism is associated with theperception of low reliability.

Our data concerning content validity indicate thatmanual passive assessment techniques are intended toprovide the therapist with information on the locationof a painful segment, the quality of the forceedisplace-ment relationship, the quantity of segmental motion,and to a much lesser extent the underlying patho-ana-tomical basis for any abnormality detected. These re-sults will inform the design and interpretation ofcriterion-related validity studies. We recommendteachers and practitioners of manual physical assess-ment techniques adopt scientifically sound and consis-tent methodology and terminology in describing theintent and content of these assessment procedures.

Acknowledgments

Thanks AAOMPT, NZMPA, in particular Ken Ol-sen and Vicki Reid; Dr Darren Rivett; and all the man-ual physical therapists who took the time to completeand submit this survey.

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