The validity of manual examination in assessing patients with neck pain

PainSci » bibliography » King et al 2007
updated Apr 16, 2025

Tags: diagnosis, neck, manual therapy, classics, head/neck, spine, treatment

Two pages on PainSci cite King 2007: 1. The Complete Guide to Low Back Pain 2. The Complete Guide to Neck Pain & Cricks

PainSci commentary on King 2007: ?This page is one of thousands in the PainScience.com bibliography. It is not a general article: it is focused on a single scientific paper, and it may provide only just enough context for the summary to make sense. Links to other papers and more general information are provided wherever possible.

“Manual therapists believe that they can diagnose symptomatic joints in the neck by manual examination,” King et al. wrote, and they had been supporting that belief with citations to a very small study Jull et al since 1988. Almost 20 years later, this study was an attempt to finally replicate those positive results. It’s worth noting that one of the authors of the original paper, Nikolai Bogduk, is also one of the authors here.

Instead of just 20 subjects, King et al. compared physiotherapist diagnoses of 173 people to more reliable testing done by “blocking” — anesthetizing — the joint.

The physical therapists seemed to be able to identify facet joints that really were hurting (good sensitivity) … but that was a hollow victory given the high prevalence of trouble at C2–C3 and C5–C6. In other words, they were merely confirming the likeliest diagnosis, like shooting fish in a barrel. “Under these conditions,” King et al. write, “the real measure of validity lies in the specificity of the test.”

But the specificity really sucked: they were terrible at ruling out facet joints that were actually just fine, thank you very much. In other words, they were finding facet flaws where there were none. In one word: overdiagnosing! Predictably, I would add.

And so the King et al. concluded that manual examination for facet joint pain “lacks validity.” That is, the results don’t mean what manual therapists think they means — despite the appearance of some decent sensitivity. Ouch.

The present study has answered the call by Jull et al. for further validation studies, but its results were negative. This outcome leaves manual examination without a sound scientific basis, and calls into question much of what is done in manual medicine and manual therapy.

~ Paul Ingraham

original abstract †Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.

BACKGROUND CONTEXT: Although manual therapists believe that they can diagnose symptomatic joints in the neck by manual examination, that conviction is based on only one study. That study claimed that manual examination of the neck had 100% sensitivity and 100% specificity for diagnosing painful zygapophyseal joints. However, the study indicated that its results should be reproduced before they could be generalized.

PURPOSE: The present study was undertaken to answer the call for replication studies. The objective was to determine the sensitivity, specificity, and likelihood ratio of manual examination for the diagnosis of cervical zygapophyseal joint pain.

STUDY DESIGN: The study was conducted in a private practice located in a rural town. The practice specialized in musculoskeletal pain problems.

PATIENT SAMPLE: The study sample was 173 patients with neck pain in whom cervical zygapophyseal joint pain was suspected on clinical examination, and who were willing to undergo controlled diagnostic blocks of the suspected joint or joints.

OUTCOME MEASURES: The validity of manual diagnosis was determined by calculating its sensitivity, specificity, and positive likelihood ratio.

METHODS: Patients who exhibited the putatively diagnostic physical signs of cervical zygapophyseal joint pain were referred to a radiologist who performed controlled, diagnostic blocks of the suspected joint, and other joints if indicated. The results of the blocks constituted the criterion standard, against which the clinical diagnosis was compared, by creating contingency tables.

RESULTS: Manual examination had a high sensitivity for cervical zygapophyseal joint pain, at the segmental levels commonly symptomatic, but its specificity was poor. Likelihood ratios barely greater than 1.0 indicated that manual examination lacked validity. Although the results obtained were less favorable than those of the previous study, paradoxically they were statistically not different.

CONCLUSIONS: The present study found manual examination of the cervical spine to lack validity for the diagnosis of cervical zygapophyseal joint pain. It refutes the conclusion of the one previous study. The paradoxical lack of statistical difference between the two studies is accounted for by the small sample size of the previous study.

original abstract †Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.

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