1994 an examination of cyriax's passive motion tests with patients having osteoarthritis of the...

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1994; 74:697-707.PHYS THER.Karen W Hayes, Cheryl Petersen and Judith FalconerWith Patients Having Osteoarthritis of the KneeAn Examination of Cyriax's Passive Motion Tests

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esearch epofl

An

Examination

of

Cyriax's Passive Motion Tests

With Patients Having Osteoarthritis of the Knee

Key Wolds

Knee, Osteoarthritis, Pain, Soft tissue syndromes.

Background and Purpose We explored the construct validity and test-retest

reliabilit?,of the passive motion component of the Cyn m soft t isue diagnosis

system. We compared the hypothesized and actual patterns of restriction, endfeel,

and pai?z/resistance sequence P/RS) of 79 subjects with osteoarthritis (OA) of the

The scheme of selective tension test- tion of force (which Cyriax called

have adopted this system to determine

ing proposed by Cyriaxl is a clinical

tension ) in different ways. The diag-

the cause of patient complaints of pain.

system of diagnosis of painful prob-

nosis is rendered based on the

The validity of the scheme is grounded

lems of soft tissues. An anatomical patient's report of pain and the

in theory and extensive clinical obser-

definition of the lesion is based on amount and direction of available

vation, but it has not been studied

the patient's response to the applica-

movement.l(p43)Physical therapists

objectively or empirically.

Karen W Hayes

Cheryl Petersen

Judlth Falconer

Physical Therapy/Volume 74 , Number 8/August 1994

697 9

knee and examined associations among these indicators of dysfunction and re-

lated constructs ofjoint motion, pain intensity, and chronicity.Subjects Subjects

had a mean age of 68.5 years (SD=13.3, range=28-95), knee stzfizess for an

average of 83.6 months (SD=122.4, range= 1-612), knee pain averaging 5.6 cm

(SD=3.1, range=O-10) on a 10-cm visual analogue scale, and at least a 10-

degree limitation in passive range of motion (ROM) of the knee.

Methods

Passive

ROM @oniometry,n=79))end-jeel (n=79), and P/RS during endfeel testing

(n=62) were assessed for extension and flexion on three occasions by one of four

experienced physical therapists. Test-retest reliability was estimated for the 2-month

period between the last two occasions. Results Consistent with hypotheses based

on Cy m sassertions about patients with OA, most subjects had capsular endfeeki

for exter~ion;ubjects with tissue approximation endfeeki or flexion had more

flexion ROM than did subjects with capsular endfeels, and the P/RS was signfi-

cantly correlated with pain intensity (rho=.35, xtension; rho =.30, lexion). Con-

trary to

hy~otheses ased on Cyrim s assertions, most subjects had noncapsular

patterns, tissue approximation endfeels or flexion, and what Cyriax called pain

synchronous with resistance or both motions. Pain intensity did not dzfer de-

pending on endfeel. The P/RS was not correlated with chronicity (rho=.03, exten-

sion; rho=-.01, lexion). Reliability, as analyzed by intraclass correlation coefi-

cients (I(XJ3, 1) and Cohen s kappa coeficients, was acceptable (1.80)or nearly

acceptable or ROM

(KC=.

71-.86, extension; ICC=.95-,9, flexion) but not for

end-jeel

K =

1

7

extension;

K

=.48, lexion) and

P/RS K

= 36, extension;

K

= 34,

jlexion). Conclusion and D2scusston The use of a quantitative definition of

the capszslar pattern, endfeeki, and P/RS as indicators of knee OA should be reex-

amined. The validity of the P/RS as representing chronicity and the reliability of

endfeel and the P/RS are questionable. More study of the soft tissue diagnosis

system is indicated. [Hayes

W

Petersen C FalconerJ An examination of Cyrim s

passive motion tests with patients having osteoarthn tis of the knee. Phys Thm

1994:7 4 . 0 -709.1

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According to Cyriax,' testing is con-

ducted in four ways: active motion,

passive motion, resisted contractions,

and palpation. The procedures are

usually performed

in

that order. Ac-

tive motion is designed to assess the

patient's willingness to move and his

or her range of motion (ROM) and

strength. Passive motion is used to

assess the amount of motion available

and the direction of limitation, if any;

the palpable sensation at the end of

passive motion (end-feel); and the

temporal sequence of pain reported

by the patient and resistance felt by

the examiner during end-feel testing

(paidresistance sequence). Resisted

testing is used to determine the reac-

tion of the muscle, tendon, and bony

attachments to contraction. Palpation

is used last to confirm the involve-

ment of the structure or structures

suggested by the previous portions of

the test. A summary of the passive

motion component of the system is

shown in the Figure, and a full de-

scription of the entire system of diag-

nosis is available in Cyriax's book.'

This report addresses only the passive

motion part of the examination. The

three components of passive motion

testing were designed to b e used to

diagnose a condition based on its

pathophysiology. Each of the compo-

nents is supposed to give additional

information. The amount and direction

of limitation of motion are examined

to determine the presence or absence

of a capsular pattern. A capsular pat-

tern is a joint-specific pattern of restric-

tion that indicates involvement of the

entire joint

capsule.l@54)A noncapsular

pattern deviates from the specfic pat-

tern and can indicate the presence of

ligamentous or partial capsular adhe-

sions, extra-articular involvement, or

internal derangements.l@53The type

of end-feel purponedly indicates the

anatomical structures that limit passive

motion (eg, bone, capsule, muscle

contraction, loose bodies in the joint,

other parts of the body) or the pa-

tient's unwillingness to complete the

motion.*@53) he paidresistance se-

quence is assessed to guide the vigor

of treatmentl@54) nd is often inter-

preted as an indicator of the chronicity

of inflammation (active, less active,

none). According to Cyriax, pain be-

fore resistance is felt by the examiner

suggests a lesion with active inflamma-

tion; pain that he says occurs synchro-

nous with resistance suggests a lesion

with less active inflammation, whereas

pain after resistance suggests a lesion

without inflammation.

The assessment system is designed to

differentiate causes of pain stemming

from inen structures (capsule, liga-

ment, fascia, bursa, nerve root, dura

mater) or contractile structures (mus-

cle, tendon, bony insertions) but is

not sufficient for a definitive diagno-

sis. Other clinical and radiographic

tests are necessary to diagnose and

discriminate problems arising from

tissues such as bone or cartilage or

neoplastic disease. Cyriaxl claims the

system can be used to identlfy pa-

tients having osteoarthritis (OA), even

though the disease primarily involves

articular cartilage. A task force of the

American Rheumatism Association

defined

osteoarthritis

as a

heterogeneous group of conditions

that lead to joint symptom s and signs

W Hayes, PhD, PT s Assistant Professor of Physical Therapy, Northwestern University Medical

School. Address cor respo nden ce to Dr Hayes at Program s in Physical Therapy, Northwestern Uni-

versity Medical School, 345

E

Sup erior St, Room 1323, Chicago, IL 60611 USA).

C P etersen, PT s Instructor i n Physical Therapy, Northwestern University M edical Sch ool.

J Falconer, PhD, OTlUL., is Associate Professor of Physical The rapy a nd M edicine Arthritis), N orth-

western University Medical School.

This study was approved by the Institutional Review Board of N orthwestern University.

This study was do ne in collaboration with wor k sup porte d by th e Arthritis H ealth Professions Asso-

ciation, Arthritis Foundation , National O fi ce , an d NIH NIAMS) Multipur pose Arthritis Cent er Grant

No. AM 30692

This article w s submitted pril

22

1993 and w s accepted January

6

1994.

which are associated with defective

integrity of the articular cartilage, in

addition to related changes in the un-

derlying bone and at the joint margins.

Although articular cartilage is poorly

innervated an d defects in cartilage are

not, in themselves, symptomatic, a

clinical syndrome of symptoms, which

often includes pain, may evolve from

these defects.Z@1039)

According to Cyriax, as the disease

develops and progresses, the capsule

and other structures surrounding the

joint become involved in predictable

ways.

@406)

Cyriax suggested that in knee OA

passive motion is restricted in a cap-

sular pattern, with proportionally

greater restriction in flexion than in

exten~ion.l@5~)e contended that a

5-

to 10-degree extension loss corre-

sponds to a 90-degree flexion loss

(extension loss is 6 -11 of flexion

loss).1@56)He suggested that early in

the development of the disease, mo-

tions end with involuntary muscle

contraction (spasm end-feel).l@~735~)

As the disease advances, patients de-

velop capsular end-feelsl@52) r hard

and painless end-feels in both exten-

sion and flexion, purportedly arising

from bone hitting bone.'@p52.406) f a

loose body were in the joint, a

springy block might be anticipated.

End-feel is related to joint motion or

pain intensity. For example, tissue

approximation is the expected end-

feel for knee flexion when the knee

has full ROM. Flexion is expected to

become limited early in OA, and the

flexion end-feel would be expected to

become a capsular end-feel as motion

is lost. Similarly, patients may be

classified as having spasm and empty

end-feels, because these types of end-

feels are painful during motion.

Cyriax stated that patients with OA are

often pain-free,l@ll)but pain could

stem from impacted loose bodies in

joints or from subchondral bone after

the cartilage is severely

Because OA is a condition of a poorly

innervated structure and leads to

decreased elasticity of the periarticu-

lar structures over an extended pe-

10 698

Physical The] apy /Volume

74,

Number 8IAugust

1994



4/13

Figure

Schematic diagram of the passive motion testing component of the selective

tension .ystem of sofr tissue diagnosis proposed

y

Cyriax 2 AROM=active range of

motion.)

P a s s i v e Range of Motion

riod of time, most patients would be

expected to demonstrate either a

painless end-feel or pain developing

after the examiner feels resistance.

Resisted testing would be strong and

painless because muscles are not

involveti in the disease.l@50)Cyriax

claimed that pain could not arise

from articular cartilage compression

resulting from the contraction be-

cause articular cartilage is not

inner~ated.~@P~>50)n addition, com-

pression would relax the ligaments

and capsule rather than stressing

them. Palpation would reveal osteo-

phytes, coarse crepitus or creaking,

and no [email protected]

equenceof pain End-feel

Amount ofmotion and resirtsnee

I

Wln Win

The primary purpose of our study

was to begin the examination of the

construct validity of the Cyriax system

of soft tissue diagnosis. The process of

construct validation of a measure is,

by definition, theory dependent. The

extent to which a measure performs

within a theoretical framework pro-

Wlnful

Something bone.

vides evidence for the validity of the

underlying construct that is measured

by the variable. Many methods are

used to examine construct validity of

a measure. For example, evidence for

validity begins to accumulate if data

show that the measure discriminates

among groups with and without the

attribute being measured, correlates

across multiple methods of measuring

the same construct, or supports hy-

potheses incorporating the construct

being measured.

In our study, we examined the con-

struct validity of the passive motion

portion of the system of selective

tension testing from two perspectives.

First, we compared the theoretically

expected pattern of restriction, end-

feel, and paidresistance sequence

with the actual assessments of patients

with OA of the knee. The hypotheses

were (1) a significant proportion of

subjects with OA will demonstrate a

capsular pattern (H:l), (2) a signifi-

with alter

resismee

esismee

cant proportion of subjects with OA

will have capsular end-feels for both

extension and flexion (H:2), and (3)

significantly more subjects with OA

will have painless end-feels or pain

after resistance than subjects who

have pain with resistance or pain

before resistance (H:3).

Am m en t with unilape) being

active m do n p~nchcd

Second, we examined relationships

among the components of passive

motion testing and joint motion, pain

intensity, and chronicity. We hypothe-

sized (1) that subjects with tissue

approximation end-feels for knee

flexion will have significantly more

passive ROM than subjects with spasm

and capsular end-feels (H:4), (2) that

subjects with spasm o r empty end-

feels will have significantly higher

pain intensity than subjects with other

end-feels (H:5), (3) that the pain/

resistance sequence will correlate

positively with pain intensity H:6),

and (4) that the pain/resistance se-

quence will correlate positively with

chronicity (H:T).

A second purpose of the study was to

estimate the reliability of the data

generated by each of the components

of the passive motion portion of the

system. The hypotheses for this por-

tion of the study were (1) there will

be no significant differences in pas-

sive ROM, end-feel, and paidresis-

tance sequence between sets of mea-

surements (H:8) and (2) test-retest

reliability estimates will exceed .80 fo

passive ROM (intraclass correlation

coefficient [ICC]),end-feel assess-

ments (kappa), and paidresistance

sequence (kappa) (H:9).

tet rnults

ess

achve ot active

Same

u

I

A R O M

a

ulw

possure

Inerlslrucbre

~ d i , ~ ~ , ~f Ex m dc ul a r Int ernal

Full sapsularproblem

lig menl

Icsion adherent derangement fmgm enro l

pan ounvc m us le . s we llin g. bone

a

l a g e ; direc tion of

Method

directionof bUrSiU6)

limitations

relate

o

location

limilationa of bl ak )

rrls1ca D pan

involved)

Subjects for the study were 79 pa-

tients with OA of the knee who had

consented to be screened for a study

of the effectiveness of ultrasound on

chronic soft tissue tightness.4 Their

OA was diagnosed by radiography or

clinical examination by physicians.

Among the important criteria for a

clinical diagnosis of OA are the pres-

ence of osteophytes, morning stiffness

for less than 30 minutes, crepitus,

C o n M t i l e

8 r n b I - e

Physical Therapy /Volume 74, Number 8/August 1994

Cap vlw Spaam Tissue Springy Bo nc ~b on e Empty

I

blT

cute onnal

a ~ u b

I

I m p l a n t

diaeaae;

m a l h t h e

acute

d e m g e ormal

h

bundtia.

logical if

innam-

yr mation

where not

rpo ted

h i k q h y t e . eumpahc

mdunited lrafrure vthmpPthY

myasitis oaaifima



5/13

-

able 1

Chara cteristics of S ubjects W ith Osteoarthritis of the Knee N =

79

vention. Evaluators did not have ac-

cess

to

previous evaluations.

Procedure

X

SD

Range

Passive ROM of the knee was mea-

Age Y)

68.5 13.3 28.0-95.0

Duration of knee stiffness mo)

83.6 122.4 1.0-612.0

Knee pain

5.6 3.1

0.0-10.0

Weight kg)

81.1 18.6 49.8-124.9

Height cm)

166.6 9.9 149.9-1 93.0

OPain measured y a 10 cm visual analog scale.

bony enlargement, and age.2 The

characteristics of the 20 male and 59

female patients are shown in Table 1.

The subjects had a mean age of 68.5

years, an average height of 166.6 cm

(65.6 in), and an average weight of

81.1 kg (179.2 lb). Subjects reported

feeling stiffness in their knees from

the disease for an average of 7 years.

On the day previous to screening,

subjects had pain in their knees aver-

aging 5.6 cm on a 10-cm visual ana-

logue scale

VAS).

All subjects had at

least a 10-degree limitation in passive

flexion and/or extension ROM.

xaminers

Four examiners participated in the

study. The examiners had practiced

physical therapy for 4 to 18 years. All

examiners were familiar with the

evaluation techniques from their pro-

fessional and postprofessional educa-

tion, and they met with each other

and the principal investigator

KWH)

to

review the measurement tech-

niques, specific study procedures, and

grading prior

to

their participation in

the study. Each examiner performed

all measures on the same set of pa-

tients at baseline, after treatment, and

after

2

months without active inter-

sured with a large universal goniome-

ter with the subjects in the supine

position with the hip flexed to 90

degrees. According to Cyriax, in OA

extension loss is 6% to 11% of flexion

loss.1@56) n our study, therefore, a

capsular pattern was defined as exten-

sion loss (with full extension defined

as 0 )eing 1% of the flexion loss

(with full flexion defined as 150 to

accommodate the maximum flexion

ROM of all subjects and to avoid

negative loss values). Extension

losses greater than 11% of flexion

loss were defined as representing a

noncapsular pattern. End-feel was

assessed at each end of passive ROM

using overpressure and assigned to

one of six categories. The pain/

resistance sequence was also as-

sessed at each end of passive ROM

and graded on a four-point scale.

These scales are shown in Table 2.

The pain/resistance sequence scale

was used in three ways. When it was

studied as an indicator of OA, subjects

with no pain and subjects with pain

after resistance were combined into

Table 2

Categories of End-feel Testing a n d Pain /Resistance Sequence Used in

one category, and subjects who had

the

pain with resistance and pain before

resistance were combined into one

category. When the pain/resistance

End feel Description

scale was used as a variable for exam-

ining the pain relationships, it was

Capsular

A hardish arrest of motion, with some give to it, feeling like

considered a four-point scale as de-

leather being stretched or as if two pieces of tough rubber

scribed. When the pain/resistance

were being squeezed together

scale was used for analysis of the

Tissue approximation

Motion ends with a sensation suggesting that motion could

concept of chronicity, subjects without

continue if not stopped by one body part contacting another

pain on

end-feel

testing

were

Springy block Noticeable rebound is seen andlor felt at end of motion

dropped from the analysis. Pain in OA

Bony An abrupt halt to movement as when two hard surfaces meet

does not correlate with stage

of

dis-

Spasm A vibrant twang suggesting that muscles have actively or

ease activity.5 Patients with early dis-

reflexively acted to end motion

ease may be pain-free, as may patients

Empty

Pain occurs before the end of motion and patient asks for the

with very advanced diseze,5 The

motion to stop; examiner feels no resistance

inclusion of a no pain category

Painlresistance sequence

would abrogate the ordinal nature of

1 No pain

the scale as a measure of chronicity.

2 Pain occurs after resistance is felt by the examiner

Pain occurs at the same time that resistance is felt by the

Pain intensity was measured by asking

examiner

subjects to mark a

VAS6

representing

4

Pain occurs before resistance is felt by the examiner

their pain intensity on the previous

day. Chronicity was measured by

12/ 700




6/13

Table 3

Extension and Flexion Ranges of Passive Motion in Degrees)

Motion and

Tlme of Measurement

S

Range n

Extensior~

Baselinea 9.77

Posttre atmentb 7.05

Follow-upb 7.46

Flexion

Baselinea 120.56

Posttreatmentb 124.25

Follow-upb 122.35

Used for validity analyses.

h ~ s e dor reliability analyses

subject report of the number of

months they had felt stiffness in their

knees resulting from their disease.

Test-retest reliability of the passive

ROM mc-asurements was estimated

using a :subset of 52 patients in the

ultrasound study who had all three

measurements taken. The data from

the posttreatment and follow-up mea-

surement sessions were used for

analysis. Although the 2-month inter-

val bemeen measurements is long,

subjects received no active interven-

tion during that period. Based on

reports from the subjects, nearly all

had continued to d o an assigned

home exercise program during this

period and to be as active as they had

been at the end of treatment. Because

the condition had been present for a

very long time in most of the subjects,

we did not expect that passive ROM,

end-feel, and pairdresistance sequence

would change markedly over 2

months. We acknowledge, however,

that change could have occurred in

these subjects and consider ou r reli-

ability estimates as containing this

source of error.

The reliability and validity of the VAS

and chronicity data were not tested.

The VAS has been reported to have

test-retest reliability (reported as Pear-

son correlation coefficients) ranging

from .91 to .977,8 nd correlations

(r)

ranging from .60 to .9OGS8ith other

measures of pain intensity. Chronicity

data were gathered by patient self-

report. Although no reliability and

validity data are available for this

particular measure, the reliability of

patient reports of other variables,

such as activities of daily living, is

acceptable, and patient reports corre-

late very highly with other methods of

gathering the same information, such

as on-site

observation.9Jo

Data nalysis

One-way chi-square analyses were

used to test the first set of hypotheses

pertaining to the proportion of sub-

jects with capsular patterns (H:l),

capsular end-feels for both extension

and flexion (H:2), and painless end-

feels or pain after resistance (H:3) at

baseline. The hypotheses that the

passive ROM of subjects with tissue

approximation end-feels would b e

larger than the passive ROM of sub-

jects with spasm o r capsular end-feels

@:4) and that the pain intensity of

subjects with spasm or empty end-

feels would be greater than the pain

intensity of subjects with other end-

*Apple Compu ter Inc,

2 525

Mariani Ave, Cupertino, CA 95104

SPSSInc, 444 N Michigan Ave, Chicago, IL 60611

feels (H:5) were tested with the

Kruskal-Wallis analysis of variance

(ANOVA) with multiple

post

ho pair-

wise comparisons.l l To examine the

relationship between the baseline

measures of pain/resistance sequence

and pain intensity (H:6) or chronicity

H:7) ,

Spearman rank correlation

coefficients (rho) were calculated.

The differences between passive ex-

tension and flexion ROM measure-

ments on the two occasions and test-

retest reliability were analyzed

individually for three evaluators (one

evaluator had only five subjects, and

the ICC was unstable) with the

ANOVA for repeated measures and

the ICC (3,1).12 The ICC (3, l) was

chosen to estimate the reliability of

the specific data of each examiner,

assuming a single measurement. The

differences between measurements of

end-feel and pain/resistance sequence

on the two occasions were analyzed

with the Wilcoxon Matched Pairs Test

and reliability was analyzed with Co-

hen's kappa coefficients.13 The alpha

level for all analyses was set at .05.

U

analyses were performed o n a per-

sonal computer* using the SPSS statis-

tical package.+

esults

The descriptive statistics for passive

extension and flexion ROM are dis-

played in Table 3. At baseline, only 8

subjects displayed a capsular pattern

and 71 subjects displayed a noncapsu-

lar pattern. The frequencies of capsu-

lar and noncapsular patterns were

significantly different (X= 50.24,

P


7/13

able 4

Number of Subjects With Each Extension and Flexion End feel

Tissue Springy

Capsular pproximation Block Bony Spasm Empty

Extension

Baselinea

59 0

4 5 7 4

Posttreatmentb

56 0 1 3 1 1

Follow-upb

45 0

2 2 3 0

Flexion

Baselinea

17 40 1 2

8 10

Posttreatmentb

11 38 2 1 3 4

Follow-upb 11 28 1 0

3 9

aUsed for validity analyses.

for reliability analyses.

subjects had a tissue approximation

end-feel, accounting for 70.0% of the

chi-square value. The hypothesis that

a significant proportion of subjects

would have capsular end-feels (H:2)

was supported for extension but not

for flexion.

The number of subjects demonstrat-

ing each category of paidresistance

sequence

is

shown

in

Table 5. Most of

the subjects had no pain, or pain

occurred with resistance. There were

few subjects in whom pain occurred

before o r after resistance. The hypoth-

esis that most subjects would have no

pain or pain after resistance (H:3) was

not supported for either extension or

flexion. There was no statistical differ-

ence in the number of subjects in the

two categories for extension

(X =2.32). The number of subjects in

each of the combined categories of

paidresistance sequence differed

from a uniform distribution (50% of

the subjects in each of the two cells)

for flexion (X =5.23, PC.05), but the

majority of the subjects were in the

Table 5 Number of Subjects With Each Extension and Flexion Sequence of Pain

and Resistance

Pain fter Pain With Pain Before

No Pain Resistance Resistance Resistance n

Extension

Baselinea

[I 7dl [29 e l 62

Posttreatmentb 28 1 18 1 48

Follow-UP

24 1 11 6 42

Flexion

Baselinea

[I 7C

sdl [29 11 62

Posttreatmentb

22 4 17 5 48

Follow-upb

17 2 17 5 41

Used for validity analyses.

for reliability analyses.

'Category dropped for analysis of pain/resistance sequence as an indicator of chronicity.

d~a tegor ies ombined for analysis of paiwresistance sequence as an indicator of osteoarthritis.

category that combined pain with

resistance and pain before resistance.

Passive ROM of flexion differed de-

pending on type of end-feel (H:4).

Passive ROM of flexion for subjects

with a tissue approximation end-feel

was greater than passive ROM of

subjects with capsular end-feels

(x2=28.13,PC.001). Pain of these

subjects did not differ depending on

end-feel (X =4.90 for extension and

x2=3.35 for flexion). The hypothesis

that subjects with spasm and empty

end-feels would have greater pain

(H:5) was not supported.

The Spearman rank correlation coeffi-

cient for paidresistance sequence and

pain intensity was .35 (n=62, P=.003)

for extension and .30 (n=62, P= ,009)

for flexion. The correlation between

paidresistance sequence and the

number of months the patient had

stiffness was .03 (n=43, P=not signifi-

cant) for extension and -.01 (n=45,

P=not significant) for flexion. These

correlations support the hypothesis

that pain/resistance sequence would

be correlated with another variable

representing pain intensity (H:6) but

not that pain/resistance sequence

would be correlated with another

variable representing chronicity (H:7).

The reliability of ROM measurements

ranged from .71 to .86 for knee exten-

sion and from .95 to .99 for knee

flexion. Passive extension and flexion

ROM did not differ between test occa-

sions (Tabs. 6 and

7).

End-feel also

did not differ between test occasions

for extension (Z=-0.31) or flexion

(Z=-1.25). The kappa coefficients for

extension end-feel and flexion end-

feel were .17 and .48, respectively,

indicating slight agreement for exten-

sion and moderate agreement for

flexion.14There were no significant

differences between the posttreatment

and follow-up measurements of

paid

resistance sequence for either exten-

sion (Z=-1.61) or flexion (Z=-0.65).

The kappa coefficients for the pain/

resistance sequence were .36 for

extension and .34 for flexion, indicat-

ing only fair agreement.14

14/ 702




8/13

Table

6

Analysis of V ariance Results for Passive Knee Extension Ra nge o f Motion

Source of Varlation l SS

S

Examiner 1

Between people 2 1 1264.91 60.23 5.79


9/13

-

ment appropriately guides diagnosis

or treatment selection.

able 7 Analysis ojvariance Results for Passiz.re Knee Flexion Range of Motion

Pain/resistance sequence

The

ource of Variation l S

F

number of subjects with no pain on

overpressure supports Cyriax's con-

tention that passive motion is often

Exam~ner

painless in OA.l(pl1)The poor reliabil-

Between people 21 28219.73 1343.80 52.51

ity for the pain/resistance sequence

Within people 22 563.00 25.59

data makes it difficult to draw conclu-

Between measures 1 29.45 29.45 1.16 NSa

Residual

2 1 533.55 25.41

Total

43 28782.73 669.37

ICCb 3,1)=.96

Examiner 2

Between people 6 4735.43 789.24 98.66


10/13

Relationshlps Among Pattern of

Restriction End-feel and

Pain/Resistance Sequence and

Related Constructs Underlying

Joint Motion Pain intensity

and Chronicity

Subjects with tissue approximation

end-feels had more ROM than sub-

jects with capsular end-feels, support-

ing a relationship between end-feel

and the underlying basis, or construct,

for joint motion. Subjects with tissue

approxirr~ation nd-feels were

ex

pected to have more ROM than sub-

jects with spasm end-feels, but they

did not. In addition, subjects with

spasm or empty end-feels were ex-

pected to have more pain than sub-

jects with other types of end-feel, and

they did not report more pain. Bear-

ing in mind the poor reliability for

the end-feel data, these results tenta-

tively support Cyriax s claim that as

the disease progresses, the flexion

end-feel changes from tissue approxi-

mation to cap ~u la r , ~@ p5 ~~ ~~ ~)ut refute

his idea that pain causes muscles to

act to limit motion.

Pain intensity on the previous day is a

composite of pain experienced during

rest and activity, both weight bearing

and non-weight bearing, and may not

be related to the level of pain experi-

enced during end-feel testing. The

relationship might be stronger if pain

intensity had been assessed at the

time of end-feel testing, as is com-

monly done clinically.

The correlation between

pain/resis-

tance sequence and pain measured

with the VAS was low but significant.

The correlation may have been low

because of the questionable reliability

of measurement of the paidresistance

sequence. To estimate the potential

magnitude of the correlations, we

corrected them for attenuation due to

~nreliability.~~ecause no reliability

data were available for the pain mea-

sure, it was assumed to have been

measured without error. The cor-

rected Spearman rank correlation

coefficients were .58 for extension

and .52 for flexion. This outcome

suggests that the paidresistance se-

quence is related to pain intensity but

is nonredundant, contributing a

unique bit of information beyond

pain averaged over daily activity.

The correlation between pain/resis-

tance sequence and the number of

months of stiffness was extremely low,

suggesting that the paidresistance

sequence is not a measure of chronic-

ity. Even when corrected for unreli-

ability, assuming that the number of

months of stiffness was measured

without error, the correlation coeffi-

cients were still low (rho=.O7 for

extension and -.02 for flexion).

If

the

paidresistance sequence represented

the concept of chronicity, then pain

after resistance would represent a

chronic state; pain with resistance

would indicate a subacute state, and

pain before resistance would indicate

an acute state. The low corrected

correlation coefficients suggest that

this pattern is not present in these

data.

In this study, the measure of chronic-

ity was the length of time the patient

felt joint

stiffness

In discussing the

paidresistance sequence, Cyriax re-

ferred to the activity of the

lesi0n.l@5~) lthough the two con-

cepts are related, months of stiffness

may not reflect the chronicity of the

tissue reaction. Nonetheless, the lack

of correlation between paidresistance

sequence and months of stiffness

diminishes the validity of using the

paidresistance sequence to indicate

the chronicity of the lesion.

Based on these data, the validity of

some of the assumptions of selective

tension testing is questionable. More

investigation of the validity of passive

motion and the other components of

the system is necessary. The diagnos-

tic accuracy of the system must be

examined in prospective studies of a

wide variety of conditions in differing

patient populations. Because results

from the knee should not be general-

ized to other joints, similar studies

should examine different joints, par-

ticularly their capsular patterns.

Reliability

The reliability estimates for measure-

ments of extension and flexion ROM

do not differ markedly from those of

other reliability studies of goniometric

measurements of knee ROM in which

intrarater reliability values of .85 to

.98 for extension and .95 to .99 for

flexion were

found.22-24 AS in these

previous studies, reliability was better

for flexion than for extension. The

lower reliability for knee extension

could reflect the

dficulty therapists

have aligning the goniometer in

ex

tension and the inability of a goniom-

eter to account for the rotation of the

tibia that occurs as the knee com-

pletes e~tension.~5his lower reliabil-

ity may also be a result of the smaller

variability in knee extension ROM

among subjects compared with the

variability of knee flexion.

The reliability estimates of end-feel

and paidresistance sequence assess-

ments may have been low because

there was limited variability in the

group on both variables. Conse-

quently, chance agreement would be

high, decreasing the kappa coeffi-

~ i e n t . ~ ~appa changes with the prob-

abilities of each of the possible cate-

gories and is best when the

probabilities are approximately equal.

The maximum possible kappa coeffi-

cient can be calculated for a given set

of marginal probabilities.13 Given the

distributions in this study, the maxi-

mum kappa coefficient would be .78

for extension end-feel, .78 for flexion

end-feel, .75 for paidresistance se-

quence in extension, and .88 for paid

resistance in flexion. For both vari-

ables, the reliability estimates are

considerably below these values. The

reliability of the paidresistance se-

quence assessments may be low be-

cause the time interval between the

onset of pain and the onset of resis-

tance may be too short to determine

clinically through manual palpation.

The low reliability estimates could

represent actual patient change over

the 2-month period; however, there

were no statistical differences in

grades between measurements, and

passive ROM reliability estimates were

acceptable or nearly acceptable over

Physical Therapy /Volume 74, Number



11/13

the same time period. We believe that

actual changes in end-feel and p a i d

resistance sequ ence are unlikely. The

reliability of both end-feel and p a i d

resistance sequ ence assessments is

probably unacceptable, but s hould b e

studied again with less time between

measurements and greate r variability

in the sample.

The low reliability estimates of th e

end-feel and pain/resistance sequence

assessments are similar to those

found by other investigators examin-

ing tests that rely on physical thera-

pists judgment of very small motion

suc h as Lachman s Test,z7 tibiofem oral

abduction,28 and tests of sacro iliac

mobility.29 Patla a nd Paris3O foun d th e

percentage of intrarater agreement of

end-feel testing of the elbow to be

75

to

80 ,

but there was little vari-

ability in th eir sam ple. Chance agree-

ment, therefore, would be high but

was not rep orted.30 Th e results of this

study undersc ore the dependen ce of

validity on reliability. It mu st b e possi-

ble to classlfy patients consistently in

the same category of end-feel o r p a i d

resistance sequence to have confi-

dence in relationships cited as evi-

dence for o r against the validity of

Cyriax s system o r to make diagnostic

and treatment decisions using the

system.

The value of studying the validity and

reliability of any measu remen t system

is to obtain data that allow refinement

of measu remen ts that are potentially

informative and to seek new systems

if existing systems are inad equate.

This study examined the passive mo-

tion components of the soft tissue

diagnosis system proposed by Cyriax.

We exam ined validity by studying

whether the three passive motion

components w ere indicators of sub-

jects with OA of the knee. We also

examined relationships among the

three indicators of dysfunction and

related constructs underlying joint

motion, pain intensity, and chronicity.

Iast, we estimated the test-retest reli-

ability of measurements of each of the

three components.

The results of this study provide evi-

dence of the need to question and

further examine selective tension

testing as a diagnostic system. Test-

retest reliability estimates w ere ac-

ceptable for passive ROM measure-

ments but not for end-feel and p ai d

resistance seque nce classification.

Very few subject. exhibited a capsular

pattern by Cyriax s quantitative defini-

tion. A propo rtional definition of a

capsular pattern sho uld be aban-

don ed, but th e concept of a pattern of

ROM loss may be useful. When cor-

rected for unreliability, paidresistance

sequence is an indicator of pain in-

tensity but not chronicity. Poor reli-

ability estimates limit o ur ability to

interpret additional findings. For ex

ample, mo re subjects retained tissue

approximation end-feels than p re-

dicted; fewer subjects had painless

end-feels or pain after resistance dur-

ing end-feel testing than predicted,

and en d-feel was related to joint mo-

tion but not to pain intensity. More

investigation of selective tensio n test-

ing is needed to improve the reliabil-

ity and exam ine o the r facets of valid-

ity, particularly the use of the system

to gu ide treatment decisions.

cknowledgments

We thank the Biostatistical and Data

Management Core of the Northwest-

er n University Multipurpose Arthritis

Center for their assistance in data

processing and data management,

especially Ahn Ch ung an d Delilah

Jones. We also thank Katie Sirianni,

PT, Linda Tiem an Roherty, PT, an d

Babette Sanders, PT, for serving as

evaluators in this study and Russell M

Woodman, PT, FSOM, OCS, for con-

sulting with us.

References

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T im e Lesions. 8th ed . Lon-

do n, England: Bailliere Tindall; 1982.

2 Altman R, Asch E, Bloch D , et al. Develo p-

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3 Ghiselli EE, Campbell JP, Zedeck S. Mea-

sureme nt Theory for the Behavio ral Sciences.

New York, NY WH Freeman and Co; 1981.

4 Falconer J, Hayes

KW

Chang RW. Effect of

ultrasound o n mobility in osteoanhritis of the

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Riddle DL, Lamb

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WJ. Reliability of goniometric measurements

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Invited Commentary

James Cyriax's views o n many aspects

of diagnosis and treatment still re-

main important within the areas of

manual therapy a nd orthope dic physi-

cal therapy. His position within physi-

cal medicine, his app ointm ent at St

Thomas' Hospital in Lon don, his for-

midable and determin ed personality,

and the certainty with which h e put

forward his views and hypotheses had

enorm ous influence at the time, and

his influence pervades much of the

literature to this day. Th ere is n o

doub t that he m ade a m ajor contribu-

tion toward the development of or -

thopedic physical therapy, promoted

active physical therapy am ong his

medical colleagues, and added sub-

stantially to th eory o n th e topic. At th e

same time, it also seems certain that

this very dominance was cou nterpro-

ductive in a n um ber of important

ways.

Cyriax was prim arily a gifted clinician,

but many of his observations on pa-

thology, o n a consideration of what

he presumed occurred in tissues and

structures d uring th e seq uence of

examination and physical testing, and

on the effects that various physical

maneuvers may have on pathology

wer e not necessarily based o n a thor-

ough und erstanding of the basic mor-

phology and subsequent pathological

change of the structures he so author-

itatively described. For these reasons,

it

is very timely that Hayes and col-

leagues shou ld objectively conside r

Cyriax's passive motion tests for pa-

tients with osteoarthritis (OA) of the

knee.

It is extremely important for physical

therapists to critically review aspects

of current treatment dogma and sub-

ject them to objective testing. In this

instance, Cyriax's views o n passive

motion testing for patients having OA

of the knee are based on clinical

observation and gro unded in his

personal theory. The hypotheses

(guesswork) associated with this the-

ory development quickly became

established do gma, and w ere ac-

cepted with little questioning by at

least a generation of physical thera-

pists an d ortho pedists. It is salutary to

note how often clinical observation

and a dominant personality have

combined to produ ce a medical belief

system, reinforced through careful

training an d effectively limiting t he

vision of large numbers of followers.'

The introduction to the article prop-

erly sets the scen e and allows the

reader to becom e quite familiar with

Cyriax's views o n passive mo tion

testing of the knee and o n the pain

and end-feel patterns that he de -

scribed as being characteristic of

various manifestations of OA. The

information provided is clear, concise,

and informative and properly d ocu-

ments Cyriax's viewpoint. The authors

then carefully sho w how they set out

to review and examine both the con-

struct validity and reliability of this

particular view of the reality of 0.4 in

the knee.

The subjects studied wer e in the main

elderly, relatively short, obes e, and

predominantly female. This subject

selection is necessarily limiting in its

29

Potter NA, Rothstein JM. Intenester reliabil-

ity for selected clinical tests of the sacroiliac

joint. Phys Ther

1985;65:1671-1675.

30

Patla CE, Paris

SV.

Reliability of interpreta-

tion of the Paris classification of normal end

feel for elbow flexion and extension.

Journal

of

Manual an d Manipulative

the rap ^ 1993;l:

60-66.

scope, something the authors readily

accept. The subjects wer e also part of

a study of the effects of ultrasound o n

chronic soft tissue tightness, presum -

ably of the knee, although this is not

stated. It would have been useful to

have had a b etter understanding of

the ultrasound study to help answer

two questions:

1

Were all of the 79 patients exam-

ined for the curren t study prior to

receiving the ultrasound?

2.

What ultrasound treatment did the

52

patients who w ere subsequently

retested

2

months later for range

of motion receive?

This information is of importance to

the reader as it has the potential to

considerably alter the state of the

tissues examined and adds an addi-

tional confounding variable to the

equation under consideration.

It is also puzzling to note that the

four examiners involved wer e se-

lected on the basis of their knowl-

edg e of the techniques in question

and had met with each othe r to

review the procedu res and tests to be

used in the study. I am surprised that

a greater effort was not ma de to e n-

sure that the examiners were carefully

trained and were shown to be able to

measure the same variables in the

same way. The in tertester reliability

doe s not appear to have been gauged

in this study, a surprising omission

given the careful nature of the rest of

the investigation. This is a consider-

able drawback to the study, as

it

raises

Physical l'herapy/Volume 74, Number B/August 1994



13/13

1994; 74:697-707.PHYS THER.Karen W Hayes, Cheryl Petersen and Judith FalconerWith Patients Having Osteoarthritis of the KneeAn Examination of Cyriax's Passive Motion Tests

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