Improving Visual Estimates of Cervical Spine Range of Motion
Cervical spine range of motion (ROM) is a common measure of cervical conditions, surgical outcomes, and functional impairment. Although ROM is routinely assessed by visual estimation in clinical practice, visual estimates have been shown to be unreliable and inaccurate. Reliable goniometers can be used for assessments, but the associated costs and logistics generally limit their clinical acceptance.
To investigate whether training can improve visual estimates of cervical spine ROM, we asked attending surgeons, residents, and medical students at our institution to visually estimate the cervical spine ROM of healthy subjects before and after a training session. This training session included review of normal cervical spine ROM in 3 planes and demonstration of partial and full motion in 3 planes by multiple subjects. Estimates before, immediately after, and 1 month after this training session were compared to assess reliability and accuracy.
Immediately after training, errors decreased by 11.9° (flexion-extension), 3.8° (lateral bending), and 2.9° (axial rotation). These improvements were statistically significant. One month after training, visual estimates remained improved, by 9.5°, 1.6°, and 3.1°, respectively, but were statistically significant only in flexion-extension.
Although the accuracy of visual estimates can be improved, clinicians should be aware of the limitations of visual estimates of cervical spine ROM. Our study results support scrutiny of visual assessment of ROM as a criterion for diagnosing permanent impairment or disability.
After this training session, each of the 4 subjects from the first round of assessments was again fitted with the harness electrogoniometer and instructed to repeat the movements in turn while examiners visually estimated cervical spine ROM and independently recorded their estimates. Meanwhile, the investigator recorded the degree of motion during each movement (as measured by the electrogoniometer). Again, a total of 840 independent visual estimates of 120 distinct movements were recorded.
Assessments Made 1 Month After Training
One month after the training session, the examiners and the investigator reconvened to assess the same 4 subjects using a procedure for simultaneous visual estimation and electrogoniometric measurement identical to that used 1 month earlier. No additional training was given. Again, 840 independent visual estimates of 120 distinct movements were recorded.
Data Analysis
The reliabilities of visual estimates were analyzed by calculating the intraclass coefficients (ICCs) using random-effect 1-way analyses of variance. By convention, ICCs of < 0.2, 0.2 to 0.39, 0.4 to 0.59, 0.6 to 0.8, and > 0.8 correspond to poor, fair, moderate, substantial, and perfect reliability, respectively.25
We compared the visual estimates and electrogoniometric measurements made for 3 planes of motion (flexion-extension, lateral bending, axial rotation) before, immediately after, and 1 month after training and drew trend lines generated by linear regression relative to a line of perfect correlation.
Mean errors in examiners’ visual estimates (relative to electrogoniometric measurements) made before, immediately after, and 1 month after training were calculated. Paired Student t tests were then used to compare the mean errors before training with the mean errors immediately after and 1 month after training.
All analyses were performed with SPSS for Windows 16.0 (SPSS, Chicago, Illinois).
Results
Inter-examiner reliability of the visual estimates in all planes of motion ranged from 0.51 to 0.79 (suggestive of moderate to substantial reliability). For reference, standard goniometers measuring knee ROM have inter-examiner ICCs of 0.89 to 0.9826 (suggestive of perfect reliability). The ICCs before, immediately after, and 1 month after training were not significantly different.
As expected, there were significant errors in visual estimates of cervical spine ROM in all planes. Initial errors in visual estimates (relative to electrogoniometric measurements) were 23.9° (flexion-extension), 15.5° (lateral bending), and 19.3° (axial rotation) (Table, Figure 3).
Immediately after training, mean errors in visual estimates decreased to 12.0° (flexion-extension), 11.7° (lateral bending), and 16.4° (axial rotation) (Table, Figure 3). In all 3 planes of cervical motion, these improvements were statistically significant.
One month after training, mean errors in visual estimates were 14.4° (flexion-extension), 13.9° (lateral bending), and 16.2° (axial rotation) (Table, Figure 3). Only the improvement in the estimate of flexion-extension (the direction of the largest error initially) remained statistically significant—a 39.7% decrease in error.
We also considered how errors varied with degree of motion observed. In flexion-extension, the tendency to overestimate at larger degrees of motion was not apparent after training, and 1 month after training we found a tendency to underestimate at smaller degrees of motion (Figure 4A). The tendency to overestimate lateral bending before training did not persist immediately after or 1 month after training (Figure 4B). Estimates of axial rotation correlated well with goniometer measurements before training and were also well correlated immediately after and 1 month after training (Figure 4C).
Discussion
Visual estimation of spinal motion is unreliable and inaccurate, but its widespread use in clinical practice continues. Goniometers are far more accurate and reliable but are seldom used. We investigated whether a training session featuring verbal instruction and demonstration with an electrogoniometer could improve visual estimates and whether potential improvement in visual estimates would remain 1 month after training.
Widely variable ICCs (0.42-0.90) have been reported for visual estimates of cervical spine ROM.17,18,22 Our findings on the reliability of these estimates are consistent with the literature.
We recorded the greatest initial error in estimates of motion in flexion-extension. Previous studies have also found the greatest error and least reliability in visual estimates in this plane.14,15,18 Visual estimation may be more difficult in flexion-extension because the shoulders cannot be used as landmarks, whereas they serve as approximate 90° reference points during estimation of lateral bending and axial rotation. Demonstration of 15°, 30° and the extremes of ROM during the training session may have provided alternative reference points during visual estimation after training—decreasing the error to within the range found in other planes of motion.
Initial errors in visual estimates were 23.9° (flexion-extension), 15.5° (lateral bending), and 19.3° (axial rotation). Based on normative cervical spine ROM in a healthy population— 126° ± 12° for flexion-extension, 86° ± 5° for lateral bending, 151° ± 23° for axial rotation22—the errors we identified are 18.9% of the normal range of flexion-extension, 18.0% of lateral bending, and 12.8% of axial rotation.
