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Identifiers Suggestive of Clinical Cervical Spine Instability: A Delphi Study of Physical Therapists

C Cook, PT, PhD, MBA, OCS, COMT, is Assistant Clinical Professor, Duke University Medical Center 3907, Durham, NC 27710 (USA) (chad.cook{at}duke.edu)
JM Brismée, PT, ScD, OCS, FAAOMPT, is Assistant Professor, Department of Rehabilitation Sciences, Texas Tech University Health Sciences Center, Lubbock, Tex
R Fleming, PT, MS, OCS, is Rehabilitation Services Manager, Ellis Hospital, Schenectady, NY
PS Sizer Jr, PT, PhD, OCS, FAAOMPT, is Associate Professor and Program Director, ScD Program in Physical Therapy, Department of Rehabilitation Sciences, Texas Tech University Health Sciences Center

Address all correspondence to Dr Cook

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.

Key Words: Cervical spine • Clinical instability • Consensus • Delphi method

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