ARTICLE IN PRESS

Manual Therapy 13 (2008) 397–403

www.elsevier.com/math

Original Article

Clinical assessment techniques for detecting ligament and

membrane injuries in the upper cervical spine region—
A comparison with MRI results
Bertel Rune Kaalea,d,, Jostein Krakenesc, Grethe Albrektsenb, Knut Westerd
a
Firda Medical Centre, P.O. Box 194, N-6821 Sandane, Norway
b
Section for Epidemiology and Medical Statistics, Department of Public Health and Primary Health Care, University of Bergen,
N-5021 Bergen, Norway
c
Section of Neuroradiology, Department of Radiology, Haukeland University Hospital, and Section for Radiology,
Department of Surgical Sciences, University of Bergen, N-5021 Bergen, Norway
d
Section for Neurosurgery, Department of Surgical Sciences, University of Bergen, and Department of Neurosurgery,
Haukeland University Hospital, N-5021 Bergen, Norway
Received 1 August 2006; received in revised form 28 January 2007; accepted 8 March 2007

Abstract

In this study we examined whether results from a clinical test of passive mobility of soft tissue structures in the upper cervical
spine, corresponded with signs of physical injuries, as judged by magnetic resonance imaging (MRI). Results were based on
examinations of 122 study participants, 92 with and 30 without a diagnosis of whiplash-associated disorder, type 2. The structures
considered were the alar and the transverse ligaments, and the tectorial and the posterior atlanto-occipital membranes. Ordinary and
weighted kappa coefficients were used as a measure of agreement, whereas McNemar’s test was used for evaluating differences in
rating. The clinical classification and the MRI examination both comprised four response categories (grades 0–3), with 0
representing a normal structure, and 3 indicating a structure with pronounced abnormality. In our sample, an abnormal clinical test
reflected a hyper- rather than hypo-mobility. Considering all four-response categories, the kappa coefficient indicated moderate
agreement (range 0.45–0.60) between the clinical and the MRI classification. The results for the membranes appeared somewhat
better than for the ligaments. When there was disagreement, the classifications obtained by the clinical test were significantly lower
than the MRI grading, but mainly within one grade difference. When combining grade 0–1 (normal) and 2–3 (abnormal), the
agreement improved considerably (range 0.70–0.90). Although results from the clinical test seem to be slightly more conservative
than the MRI assessment, we believe that a clinical test can serve as valuable clinical tool in the assessment of WAD patients.
However, further validity- and reliability studies are needed.
r 2007 Elsevier Ltd. All rights reserved.

Keywords: WAD; Manual therapy; MRI; Clinical assessment; Upper cervical spine

1. Introduction

The diagnosis of whiplash associated disorder (WAD)

Corresponding author. Firda Medical Centre, P.O. Box 194,
N-6821 Sandane, Norway. Tel.: +47 57 86 64 22; fax: +47 57 86 94 70.
E-mail addresses: kaale@c2i.net (B.R. Kaale),
jostein.krakenes@helse-bergen.no (J. Krakenes), msega@uib.no
(G. Albrektsen), kgwe@helse-bergen.no (K. Wester).
has traditionally been based on the patient history
weighted against well-known symptoms associated with
a whiplash trauma. It has been difficult to find evidence
of physical signs of injuries, partly due to lack of
knowledge regarding what structures to focus on. In our
recent studies (Krakenes et al., 2001, 2002, 2003a, b),

1356-689X/$ - see front matter r 2007 Elsevier Ltd. All rights reserved.
doi:10.1016/j.math.2007.03.007
 ARTICLE IN PRESS
398 B.R. Kaale et al. / Manual Therapy 13 (2008) 397–403
however, we have described how specific ligaments
and membranes in the upper neck region can be
visualised and classified by magnetic resonance imaging
(MRI). We also found a consistent association between
degree of subjective symptoms and complaints among
the WAD patients and severity of MRI-verified
abnormalities (Kaale et al., 2005a). Moreover, the
MRI abnormalities appeared to be associated both
with the head position and direction of impact during
the collision, indicating that the structural abnor-
malities indeed are consequences of the whiplash trauma
(Kaale et al., 2005b). Objective, clinical tests for
evaluation of insufficiency of a specific neck structure
has so far not been a part of the clinical evaluation of
WAD patients. Results from a well-defined clinical test
of passive range of motion may provide valuable
information about potential location of an injury,
possibly leading to fewer and more specific MRI
evaluations.
The ligaments and membranes in the upper cervical
spine are bands of dense connective tissue, comprising
collagen and elastic fibres that have an important role
for controlling normal joint movement of the head and
neck (Hildebrand and Frank, 1998; Woo et al., 1999).
If these structures are injured, an abnormally increased
mobility in this region may be expected. It may be
possible to detect such increased mobility by a
physical examination. In our previous studies based
on MRI, the highest prevalence of abnormal findings
was found for the alar ligaments (Kaale et al., 2005a),
and abnormalities of this structure also showed the
most consistent association with subjective symptoms
(Kaale et al., 2005a). The alar ligaments have an
important role both in rotation, flexion and side bending
in the upper cervical spine (Williams and Warwick,
1980; Dvorak and Panjabi, 1987; Crisco et al., 1991).
Since they are multifunctional, an abnormality on MRI
of these ligaments will not necessarily provide informa-
tion about specific clinical consequences. However,
a clinical examination may enable us to assess
both whether there is a ligament or membrane
insufficiency, as well as to determine more specifically
the direction or combination of directions of a pos-
sible hyper-mobility due to this insufficiency. Such
information may be of value in further treatment of
the patient.
The aim of the present study is to investigate whether
a clinical test of passive mobility of ligaments and
membranes in the upper cervical spine, can be used as an
objective indicator for soft tissue lesions in WAD
patients. To do so, we assessed degree of agreement
between the results from a clinical test and an MRI
evaluation. Five different neck structures were consid-
ered; the left and right alar ligaments, the transverse
ligament, the tectorial membrane and the posterior
atlanto-occipital membrane.
2. Material and methods
2.1. Study participants
During the period September 1999 to March 2000, 93
WAD patients (corresponding to type 2 of the Quebec
Task Force of Whiplash Associated DisorderWADs;
Spitzer et al., 1995) and 38 persons without a diagnosis
of WAD, who all had agreed to participate in this study,
were assigned a time and date for an MR examination,
as well as a clinical examination. More detailed
information on the selection of study participants has
been given previously (Kaale et al., 2005a). Among the
WAD patients, the mean time from collision to the
clinical testing was 5.7 years (range 1.9–9.0 years). Thus,
only patients with chronic symptoms were included, and
no patients in the acute phase were considered. The
clinical test took place within two weeks before the MRI
assessment, and the MRI readings were performed
without knowledge of the results from the clinical test or
diagnostic status. Eight of the 38 persons without a
WAD diagnosis failed to present for the MRI examina-
tion, and one of the 93 WAD patients had insufficient
quality on the MRI due to claustrophobia, and was
excluded. Thus, a total of 92 WAD patients and 30
persons without a WAD diagnosis were eligible for
analyses.
2.2. MRI classification
The MRI examinations were performed with a 1.5 T
system (Magnetom Vision; Siemens Medical System,
Erlangen, Germany). A standard head coil was used,
and proton density-weighted sequences with 2 mm thick
slices were obtained in three orthogonal planes with the
head and neck in a neutral position (Krakenes et al.,
2001).
Each ligament and membrane was classified in one
out of four possible predefined categories, referred to as
MR grade 0–3. The following classification system was
applied: Grade 0 reflected a normal structure. The alar
and transverse ligaments were classified as grade 1 when
less than one third of the cross section area showed
increased signal intensity, as grade 2 when more than
one third, but less than two thirds, showed increased
signal intensity, and as grade 3 when more than two
thirds of the cross section area showed increased signal
intensity. The posterior atlanto-occipital membrane was
evaluated indirectly by changes in the adjacent dura
mater. An irregularity or thinning of the dura was
classified as grade 1, discontinuity as grade 2, and
discontinuity with a dural flap as grade 3. Grade 1–3
classification of the tectorial membrane was diagnosed
when less than one third, between one third and two
thirds, and more than two thirds of the membrane
was absent, and only the dura mater was remaining.
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B.R. Kaale et al. / Manual Therapy 13 (2008) 397–403
More detailed information on the MRI-protocol,
visualisations, and reliability of the classification criteria
is given elsewhere (Krakenes et al., 2002, 2003a, b).
2.3. The clinical classification
Within manual therapy, tests of passive intervertebral
movements (PIMs) of the cervical spine are frequently
used for patients with neck pain (Trijffel van et al.,
2005). The clinical test used in the present study is based
on evaluation of PIM. Such test techniques, however,
has in general not been applied in relation to WAD, or
for testing the neck structures considered in the present
study.
The test for each single structure considered in the
present study has specific test movements, and aims at
clarifying the ability to withstand passive stretching. A
specialist in manual therapy (BRK) performed the
clinical examination while the patient was sitting in a
chair. Passive stretching of the ligament and membrane
was performed through the passive range of motion, or
until a muscular contraction occurred due to pain in the
area. The predefined clinical categories (category 0–3)
were as follow: Category 0 indicated a normal ligament
or membrane function. In category 1, a minor increase
in motion between test points was found, in category 2 a
moderately abnormal motion was found, and in
category 3 an extensive increase in motion between test
points was found. Illustrations of performance of the
PIM tests are shown in Fig. 1a–d.
2.4. Statistical analyses
A joint analysis of persons with and without a WAD
diagnosis was performed to ensure sufficient variation in
normal and abnormal findings in the study sample. The
kappa coefficient was used as a measure of agreement
between the classifications based on the clinical test and
the MRI evaluations. Categories 0–3 on the clinical test
were compared with grade 0–3 from the MRI assess-
ment. Both ordinary and weighted kappa values were
calculated. In contrast to the ordinary kappa coefficient,
which consider only complete agreement between the
two judgements, the weighted kappa coefficient gives
some additional weight to classifications that are close
(original response ordinal). In the present study, a
difference between the two classifications of 0, 1, 2 and 3
was given linear weights 1, 0.67, 0.33 and 0, respectively.
In addition, ordinary kappa was calculated on dichot-
omized response, i.e. with the two best (grade/category
0–1) and two worst (grade/category 2–3) categories
combined. The absolute values of the kappa coefficient
range from 0–1 (negative values indicate poorer agree-
ment than expected by chance). Values less or equal to
0.20 are interpreted as poor agreement, 0.21–0.40 as fair
agreement, 0.41–0.60 as moderate agreement, 0.61–0.80
399
as good agreement, and values above 0.80 indicate very
good agreement (Altman, 1994).
The sensitivity, specificity and positive and negative
predictive values (PPV, NPV) for the clinical test vs. MR
were also calculated on the basis of the dichotomised
responses, i.e. grade/category 0–1 considered as normal,
and grade/category 2–3 considered as abnormal.
3. Results
Considering all four-response categories/grades, the
kappa coefficient showed moderate agreement (range
0.45–0.60) between the clinical and the MRI classifica-
tions (Table 1). Most disagreements were close, how-
ever, and when adding weight also to cases without
complete agreement in the calculations, the weighted
kappa coefficient indicated good agreement (range 0.62–
0.78). The results for the membranes were somewhat
better than for the ligaments (Table 1). When dichot-
omising the classification results by combining the two
best (0–1) and two worst (2–3) categories (Table 2),
agreement was good for the ligaments (values close to
0.70), and very good for the two membranes (values
above 0.90). The very high degree of agreement for the
membranes is probably partly related to the low
prevalence of abnormal findings for these structures.
In the case of disagreement, the structures were rated
significantly lower by the clinical test than by the MRI
classification (Table 1, McNemar’s test). However, in
most cases the clinical and MRI classifications differed
by only one grade. For the two membranes, the
disagreement was almost completely restricted to a
classification of grade 1 by the radiological classifica-
tion, whereas the same patient was classified as grade 0
by the clinical test. When combining the two lowest and
highest categories/grades, there was no systematic
difference between the classifications of the membranes,
but a significant difference remained for the ligaments
(Table 2). For the right and the left alar ligaments, the
disagreement was then 13.9% and 14.7%, respectively.
The corresponding number for the transverse ligament
was 13.1%.
The sensitivity, specificity and positive and negative
predictive values (PPV, NPV) of the clinical test vs. MRI
for the different ligaments and membranes were in
general rather good (Table 3). For the two ligaments,
however, about 30–35% of the abnormal MRI results
did not have a clinically detectable correlate (sensitivity
of 0.69, 0.72 and 0.65 for right and left alar ligaments,
and the transverse ligament, respectively). This result
improved considerably when categories 1–3 (minor,
moderate and considerable hyper-mobility) were all
considered as abnormal on the clinical test (sensitivity
changed to 0.89, 0.85, and 0.95, respectively). The
NPV also improved slightly with this redefinition of
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abnormality on the clinical test, whereas the specificity
and PPV were somewhat worsened (results not shown),
in particular for the transverse ligament (specificity
decreased from 0.99 to 0.73, and PPV decreased from
0.97 to 0.66).
4. Discussion
The present study indicated good agreement between a
clinical examination and MRI in the assessment of
abnormalities of ligaments and membranes in the upper
cervical spine. The high degree of agreement when
classifying into normal/abnormal categories indicate that
it is possible to detect lesions of these structures by a
clinical examination, and conversely, that MRI findings
are of clinical relevance. Results from the present study
thus indicate that the clinical assessment techniques have
a potential for being a useful clinical tool, and may serve
as an initial tool for location of an injury.
To our knowledge, this is the first study that has
reported results from a clinical test of soft-tissue
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Table 1
Agreement in classification of lesions to ligaments and membranes in the upper cervical spine areaa, as judged by means of manual therapy techniques
(MT, 1 manual therapist) and MRI-reading (MRI, 1 radiologist)

Neck structure MT compared with MRI Ordinary Weighted p-valuec

kappa coefficient kappa coefficient
% Both % Both % Both % Both % (95% C.I.) (95% C.I.)
grade 0 grade 1 grade 2 grade 3 Disagree

Ligaments
Alar, right 33.6 1.6 10.7 15.6 38.5 0.45 (0.35–0.57) 0.66 (0.58–0.75) o0.001
Alar, left 33.3 2.5 11.5 13.9 38.8 0.45 (0.34–0.56) 0.62 (0.52–0.72) o0.001
Transverse 35.2 11.5 9.0 11.5 32.8 0.53 (0.41–0.64) 0.69 (0.60–0.78) o0.001
Membranes
Tectorialb 64.1 5.8 8.3 3.3 18.5 0.60 (0.45–0.74) 0.72 (0.60–0.84) o0.001
Atlanto-occ.b 62.8 0.8 8.3 9.1 19.0 0.60 (0.46–0.74) 0.78 (0.68–0.87) o0.001
a
Results based on 122 persons: 92 WAD2 patients and 30 healthy individuals.
b
One missing value.
c
McNemar’s test for systematical differences.

structures in the upper cervical spine compared to the
results of a radiological method. Our initial step in
evaluating the usefulness of these tests has been to
compare with results from an MRI classification shown
to correlate well with subjective symptoms in the WAD
patients (Kaale et al., 2005a). The clinical tests were
based on techniques within manual therapy, and were
performed by a specialist in manual therapy (BRK) with
long experience in application of these tests on WAD
patients. Results from validity and reliability studies of
PIMs, although used in other circumstances and for
other structures that the one tested in the present study,
have varied somewhat (Trijffel van et al., 2005; Piva
et al., 2006). The performance of the clinical test will
depend on the experience of the clinician. A clear
definition of classification criteria as well as application
of it, are needed in order to apply these test techniques
successfully in an ordinary clinical setting.
In the assessment of agreement, we directly compared
loss of collagen integrity as judged by MRI (grade 0–3),
with degree of increased mobility as judged by the
clinical examination (category 0–3). We thus explored
whether signs of a physical injury of a specific neck
structure affected the passive mobility of that structure.
In most cases of disagreement, it was an abnormal MRI
result that did not have a clinical correlate, rather than
the opposite. The sensitivity for the clinical test vs. MRI
improved when changing the definition of abnormality
on the clinical test to include category 1 (minor hyper-
mobility), rather than only categories 2–3 (moderate and

Fig. 1. (a–d) Illustrations of the clinical test techniques. The passive intervertebral movement (PIM) tests assess the occipital-atlas-axis mobility.
Each test put stress on individual soft tissue structures, and the test try to qualify the tested motion. In all test procedures, the person’s head rests
against the chest of the examiner, acting as a stabilising factor. (a) Test of the alar ligaments. The test of the alar ligaments assesses the quality of
rotation between occipital-atlas-axis. Insufficiency of the ligament gives a hypermobil function in this area. Test procedures: Both hands are placed on
the same side of the person’s cervico-occipital junction. The lower (right) hand stabilises C2 by pressing finger 2 and 3 against the lateral aspect of
C2—pulling this part backwards. The test of the ligament is performed by an upward pull into rotation with two fingers on the left hand, one finger is
placed (finger 3) under the lateral mass of atlas, and finger 2 is placed under the mastoid processus. The test is performed with different
angles of cervical rotation, to locate the exact test position that gives the maximal movement between C1 and C2. (b) Test of the transverse ligament.
The test of the transverse ligament assesses the ventral/ dorsal translation of atlas against axis. Insufficiency of this ligament gives an excessive
translation of atlas. Test procedures: C2 is stabilised by a frontal grip. This stabilisation is performed by pressing the thumb against the frontal part of
the left lateral process, while fingers 2 and 3 are pressed against the right lateral process. It is important that the finger grip must not give a feeling of
strangling. The test movement is performed by pressing the thumb against the posterior part of the left lateral mass of atlas, while holding finger 2
against the lateral mass on C1 on the opposite side. At the same time, fingers 1 and 2 are pressed firmly against the inferior part of the occiput. The
flexed fingers 3–5 support the grip from below. C1 (occiput follows the movement of atlas) is pressed forward and C2 is pressed backwards, testing
the translation of dens axis in the space from the transverse ligament to the posterior part of C1. The test is performed from neutral position between
C1 and C2, and through several steps of increasing flexion. (c) Test of the tectorial membrane. The test of the tectorial membrane assesses degree of
ventral horizontal translation between occiput-atlas-axis. The right hand, that performs the passive test movement, is placed in the suboccipital
region. Fingers 1 and 2 are formed as a semicircle, and are pressed against the lower part of occiput. Finger 1 and 2 are supported from below by
flexed fingers 3, 4 and 5. C1 is following the ventral and cranial movement of the occiput. C2 is stabilized by a frontal grip. The test movement goes
forward combined with a traction force. The test is performed with different angles of flexion and degrees of traction. A positive test result is given by
an excessive translation between occiput/ C1 and C2. (d) Test of the posterior atlanto-occipital membrane. The test of the posterior atlanto-occipital
membrane assesses the stability in the posterior part of the neck between occiput and atlas. Both hands are placed in the suboccipital region. The
lower (right) hand is stabilising the C1 by a downward pressure with thumb and fingers placed on the lateral mass of atlas. The upper (left) hand is
formed as a grip, with the fingers directed downwards. The test is performed by pulling with the left hand in the opposite direction of the downward
pressure performed by the other hand. The pulling is repeated several times through different angles of flexion.
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Table 2
Agreement in classification of lesions to ligaments and membranes in the upper cervical spine areaa, as judged by means of manual therapy techniques
(MR, 1 manual therapist) and MRI-reading (MRI, 1 radiologist)

MT compared with MRI

% both normala % both abnormalb % disagree Kappa coefficient (95% C.I.) P-valuec

Alar ligament, right (n ¼ 122) 55.7 30.3 13.9 0.71 (0.58–0.83) o0.001
Alar ligament, left (n ¼ 122) 53.3 32.0 14.8 0.69 (0.57–0.82) 0.008
Transverse ligament (n ¼ 122) 63.9 23.0 13.1 0.69 (0.55–0.83) 0.001
Tectorial membrane (n ¼ 121) 86.0 12.4 1.6 0.93 (0.83–1.03) 1.00
Atlanto-occ. membrane (n ¼ 121) 81.0 18.2 0.8 0.97 (0.92–1.03) 1.00
a
For MT evaluation, normal correspond to normal or minor increase in motion, and for MRI, normal correspond to grade 0 or 1.
b
For MT evaluation, abnormal correspond to moderately or extensively increased motion, and for MRI, abnormal correspond to grade 2 or 3.
c
McNemar’s test for systematical differences.

Table 3
Number of classifications and diagnostic values for manual therapy vs. MRI classifications for ligaments and membranes in the upper cervical spine,
calculated on the basis of classifications of 122 persons; 92 WAD patients and 30 control persons

MRI-grade: 0–1 2–3 0–1 2–3 Sensitivitya Specificityb PPVc NPVd

MT-grade: 0–1 2–3 2–3 0–1 (95% C.I) (95% C.I) (95% C.I) (95% C.I)

Alar ligament, right 68 37 0 17 0.69 (0.56–0.81) 1.00 (1.00–1.00) 1.00 (1.00–1.00) 0.80 (0.71–0.89)
Alar ligament, left 65 39 3 15 0.72 (0.60–0.84) 0.96 (0.91–1.00) 0.93 (0.85–1.01) 0.81 (0.73–0.90)
Transverse ligament 78 28 1 15 0.65 (0.51–0.79) 0.99 (0.96–1.01) 0.97 (0.90–1.03) 0.84 (0.76–0.91)
Tectorial membranee 104 15 1 1 0.94 (0.82–1.06) 0.99 (0.97–1.01) 0.94 (0.82–1.06) 0.99 (0.97–1.01)
Atlanto-occ. membranee 98 22 0 1 0.96 (0.87–1.04) 1.00 (1.00–1.00) 1.00 (1.00–1.00) 0.99 (0.97–1.01)
a
Sensitivity is the proportion classified as abnormal by MRI (grade 2–3) that are classified as abnormal also by MT (grade 2–3).
b
Specificity is the proportion classified as normal by MRI (grade 0–1) that are classified as normal also by MT (grade 0–1).
c
PPV (positive predictive value) is the proportion classified as abnormal by MT (grade 2–3) that are classified as abnormal also by MRI
(grade 2–3).
d
NPV (negative predictive value) is the proportion classified as normal by MT (grade 0–1) that are classified as normal also by MRI (grade 0–1).
e
1 missing value.

major hypermobility). In view of normal variation and
difficulties with interpretations of the MRI (Krakenes
et al., 2001, 2002, 2003a, b), false positive results based
on MR cannot be ruled out. Nevertheless, MRI is so far
regarded as the best tool in visualising the collagen
integrity of soft tissue structures (Erickson, 1997), and
was considered to represent the ‘gold standard’ in the
present study.
In general, we achieved better agreement between the
clinical test results and the MRI classification for the
membranes than for the ligaments. This may be due to a
considerably lower prevalence of membrane injuries in
our material, but may also be related to the higher
elasticity of the membranes, making them easier to
assess clinically than the thicker and stiffer ligaments.
For the membranes, the test techniques can be
performed through a longer range of passive motion,
and therefore the dysfunction can be detected more
easily. The alar and the transverse ligaments are short
and strong, with a higher content of non-elastic collagen
fibres, compared with the two membranes (Williams and
Warwick, 1980). Thus, for the ligaments, the tested
range of motion is smaller, and we have a shorter
distance to perform the test, compared with the testing
of the membranes. Pain raised from the examined area
can increase the muscular tension, and thereby also
influence the performance of the clinical test. Individual
differences in soft tissue stiffness may also be of
importance. Classifications into normal/ abnormal
categories improved agreement between clinical and
radiological test results. In view of individual variations
as well as difficulties with performing the clinical tests, a
two-grade system (normal, abnormal) is probably most
efficient in an ordinary clinical setting.
The ligaments and membranes in the upper cervical
spine participate in different combinations of functions
(Williams and Warwick, 1980; Crisco et al., 1991;
Dvorak et al., 1991). Which structure and what part
of it that is injured are probably decisive for how it will
affect the cranio-vertebral mobility. Direction of ex-
ternal and internal forces during the whiplash trauma
has been found to be of importance for what structures
are injured (Kaale et al., 2005b). For a purposeful and
efficient MRI examination, it is essential to know what
specific area or structure to focus on. The present
findings of a clinically detectable hyper-mobility in
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B.R. Kaale et al. / Manual Therapy 13 (2008) 397–403
many of the patients with MRI-verified lesions indicate
that a clinical examination can be quite valuable in
localising structures or areas with a possible lesion when
performing the MRI examination. A clinical test can
also determine more specifically what particular
movements that are affected. A detailed assessment of
the location of an injury, as well as its clinical
consequences, is of vital importance for the planning
of an efficient rehabilitation. For instance, a training
programme aimed at strengthening the surrounding
muscles groups in the cranio-vertebral junction may
compensate for potential consequences of injured
passive neck structures, even for patients with no
abnormal MRI findings.
In summary, results from the present study indicate
that it is possible to detect joint dysfunction in the upper
cervical spine by a clinical examination. The results of
the clinical tests corresponded reasonably well with the
MRI assessments. In view of our previous findings, the
observed clinical and radiological abnormalities do seem
to be of clinical significance. These findings are of
importance for the understanding of the mechanisms
behind the WAD syndrome, as well as for the treatment
of this condition. To further develop the clinical test
procedures, additional validity and reliability studies are
needed. A multidisciplinary approach is probably
needed for achieving an optimal assessment- and
treatment protocol for WAD patients.
References
Altman D. Practical statistics for medical research. London: Chapman
& Hall; 1994.
Crisco JJ, Panjabi MM, Dvorak J. A model of the alar ligaments of the
upper cervical spine in axial rotation. Journal of Biomechanics
1991;24:607–14.
Dvorak J, Panjabi MM. Functional anatomy of the alar ligaments.
Spine 1987;12:183–9.
403
Dvorak J, Panjabi MM, Novotny JE, Antinnes JA. In vivo flexion/
extension of the normal cervical spine. J. Orthop. Res. 1991;9(6):828–
34.
Erickson SJ. High-resolution imaging of the musculoskeletal system.
Radiology 1997;205:593–618.
Hildebrand K, Frank C. Scar formation and ligament healing. CJS
1998;6:425–9.
Kaale BR, Krakenes J, Albrektsen G, Wester K. WAD impairment
rating: neck disability index score according to severity of MR-findings
of ligaments and membranes in the upper cervical spine. Journal of
Neurotrauma 2005a;4:466–75.
Kaale BR, Krakenes J, Albrektsen G, Wester K. Head position and
impact direction in whiplash injuries—associations with MR verified
lesions of ligaments and membranes in the upper cervical spine.
Journal of Neurotrauma 2005b;11:1294–302.
Krakenes J, Kaale BR, Rorvik J, Gilhus NE. MRI assessment of
normal ligamentous structures in the craniovertebral junction.
Neuroradiology 2001;43:1089–97.
Krakenes J, Kaale BR, Moen G, Nordli H, Gilhus NE, Rorvik J. MRI
assessment of the alar ligaments in the late stage of whiplash injury—a
study of structural abnormalities and observer agreement. Neuror-
adiology 2002;44:617–24.
Krakenes J, Kaale BR, Moen G, Nordli H, Gilhus NE, Rorvik J.
MRI of the tectorial and posterior atlanto-occipital mem-
branes in the late stage of whiplash injury. Neuroradiology
2003a;45:585–91.
Krakenes J, Kaale BR, Moen G, Nordli H, Gilhus NE, Rorvik J. MR
analysis of the transverse ligament in the late stage of whiplash injury.
Acta Radiologica 2003b;44:637–44.
Piva SR, Erhard RE, Childs JD, Browder DA. Inter-tester reliability
of passive intervertebral and active movements of the cervical spine.
Manual Therapy 2006;11:321–30.
Spitzer WO, Skovron ML, Salmi LR, Cassidy JD, Duranceau J, Suissa
S, et al. Scientific monograph of the Quebec Task Force on Whiplash-
Associated Disorders: redefining ‘‘whiplash’’ and its management.
Spine 1995;20S:1–73.
Trijffel van E, Anderegg Q, Bossuyt PM, Lucas C. Inter-examiner
reliability of passive assessment of intervertebral motion in the cervical
and lumbar spine. Manual Therapy 2005;10:256–69.
Williams PL, Warwick R. Gray’s Anatomy. New York: Churchill
Livingstone; 1980.
Woo S, Hildebrand MD, Watanabe N, Fenwick J, Papagergiou C,
Wang J. Tissue engineering of ligaments and tendon healing. Clinical
Orthopaedics and Related Research 1999;376S:312–23.