Aplicación Propuesta y resultados Esperados

Four literature reviews have previously been published regarding reliability and/or validity studies for the measurement of cervical spine ROM [101, 160, 197, 198].

The primary objective of the first of these reviews by Chen et al [101] was to carry out a meta-analysis of normative cervical motion but also incorporated a narrative review of the reliability and clinical validity of the studies. A search performed solely using Medline (1966 to 1998) was not specific to reliability and/or validity studies, merely using the key words ―range of motion‖ and ―cervical‖. Data extracted for reliability and variability of methods were averaged within each study and organised by technology. 45 papers were retrieved for the meta-analysis of normative motion; 17 of these papers reported reliability studies and seven papers reported validity studies. The authors concluded that reliability was

inappropriately and inconsistently analysed and suggested that future studies should include a comprehensive quantitative analysis using Intra-class Correlation Coefficients (ICC) and

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Limits of Agreement (LoA) statistical techniques in parallel. They argued that true validation of tools to measure cervical ROM is not possible as there is no true gold standard of

measurement and that often intra-technology variability of measurements are as large as or larger than inter-technology variability. From this they deemed measurement protocols and examiner training to be as important as the technology itself. From the papers reviewed it was unclear whether passive ROM is more reliable than active ROM. It was deemed clearer that full cycle movements are more reliable than half-cycle ones.

The second review by Antonaci [160] was purely narrative with no details of how or what types of literature were obtained. 15 reliability studies were referenced however results were only selectively reported. The papers were discussed in groups according to the technology, and tables usefully provide details of advantages and disadvantages of each method. No conclusions were offered as to preferable methods of measurement, although the abstract stated that ―Cybex and 3D kinematic analysis by means of opto-electrical scanners (Elite system) seemed to be the most reliable and reproducible methods.‖[160]

The third review, conducted by Jordan and published in 2000 [197], assessed 21 reliability studies systematically, although meta-analysis was deemed inappropriate due to

heterogeneity of the included studies. A search strategy was used on 11 different electronic databases, followed by data extraction and a qualitative assessment of included papers. A thorough discussion of methodological considerations for reliability studies was offered including use of appropriate statistical techniques, sample size calculations, standardised measurement protocol along with analysis of the relative reliability of the various tools. He concluded that the Cervical Range of Motion device (CROM; a combination of gravity and compass goniometers) is the most promising method although further, more rigorous investigation of all tools is warranted.

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The final review of studies (de Koning et al[198]) was published in April 2008 as the author‘s systematic review was being written-up. This clearly justifies there was a need for an up-to-date systematic review to be conducted at this time. The research question was very similar in that it tried to establish the most appropriate method for assessing cervical ROM; however de Koning et al‘s review was limited to active ROM in patients with non- specific neck pain. It could be argued that the research objective of the review described below is more ambitious, incorporating passive ROM and all types of sample populations. It was deemed important to consider reliability and validity of methods measuring passive ROM as this is a commonly used impairment measure which is thought to provide its own unique information regarding the state of tissues and in conjunction with active ROM measurement will add to the often complex biopsychosocial picture that is the clinical examination. It is also noted that although de Koning et al [198]stated they were trying to establish the most appropriate method of assessing ROM in non-specific neck pain patients, only nine of the articles included involved a non-specific pain population. Absence of discussion of this point in the article is notable.

The review by de Koning et al [198] included 33 papers and evaluated not only reliability and validity of methods but also responsiveness and interpretability. 23 of the 33 articles are included in the systematic review described below, with the other 10 having been excluded for statistical reasons described in the methods section below. The review of de Koning excluded devices that were not portable, affordable (max 1,000 Euros) and easy to use (time to test max 5 min) by Allied Health Professionals in daily practice. Similarly to Jordan [197], de Koning et al [198] did not attempt meta-analysis, although a progression was made in that a quality assessment tool was devised and utilised to provide some standardised

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(probably due to the brevity required in this published format) and this would undoubtedly have been useful for future investigations. De Koning et al‘s [198]discussions and analyses incorporate both research and clinical issues and conclude that ―both the CROM device and single inclinometer can be considered appropriate instruments.‖

Similar conclusions drawn from all four of the literature reviews suggest that improvements to methodology and reporting can be made to future reliability and validity studies although more recent studies suggest that researchers are heading in the right direction [198]. In terms of the methodology for literature reviews in this area, the main challenge is the lack of agreed quality assessment criteria for these types of studies. It is clear that until methodology and reporting of these studies is more homogeneous the advantages that result from meta- analysis will continue to be absent.