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Summary
Background: Neck reflex points (NRP) are tender soft tissue
areas of the cervical region that display reflectory changes in
response to chronic inflammations of correlated regions in the
visceral cranium. Six bilateral areas, NRP C0, C1, C2, C3, C4 and
C7, are detectable by palpating the lateral neck. We investigated the inter-rater reliability of NRP to assess their potential
clinical relevance. Methods: 32 consecutive patients with
chronic neck pain were examined for NRP tenderness by an experienced physician and an inexperienced medical student in a
blinded design. A detailed description of the palpation technique is included in this section. Absence of pain was defined
as pain index (PI) = 0, slight tenderness = 1, and marked
pain = 2. Findings were evaluated either by pair-wise Cohens
kappa () or by percentage of agreement (PA). Results: Examiners identified 40% and 41% of positive NRP, respectively (PI > 0,
physician: 155, student: 157) with a slight preference for the left
side (1.2:1). The number of patients identified with >6 positive
NRP by the examiners was similar (13 vs. 12 patients). values
ranged from 0.52 to 0.95. The overall kappa was = 0.80 for the
left and = 0.74 for the right side. PA varied from 78.1% to
96.9% with strongest agreement at NRP C0, NRP C2, and NRP
C7. Inter-rater agreement was independent of patients age,
gender, body mass index and examiners experience. Conclusion: The high reproducibility suggests the clinical relevance of
NRP in women.
2016 S. Karger GmbH, Freiburg
Schlsselwrter
Nackenschmerzen Muskel-Triggerpunkte Neuroreflektorische
Vernderungen Zahnherde Neuraltherapie
Zusammenfassung
Hintergrund: Nackenreflexpunkte (NRP, Adler-Langer-Punkte)
sind schmerzhafte Bindegewebsareale an Hals und Nacken, die
bei chronischen Entzndungen des viszeralen Kraniums auftreten knnen. Je 6 Punkte, NRP C0, C1, C2, C3, C4 und C7, lassen
sich beidseits palpatorisch unterscheiden. Wir untersuchten
deren Reproduzierbarkeit, um Hinweise auf ihre mgliche klinische Relevanz zu erhalten. Methode: 32 aufeinanderfolgende
Patienten mit chronischen Nackenschmerzen wurden in einem
verblindeten Studiendesign durch einen erfahrenen Arzt und
eine ungebte Anfngerin (Medizinstudentin) auf NRP untersucht. Die Untersuchungstechnik der NRP wird detailliert beschrieben. Die Schmerzhaftigkeit wurde mittels eines Schmerzindex (PI) von 02 definiert, wobei leichter Druckschmerz als 1
und deutlicher Schmerz als 2 bezeichnet wurde. Die Ergebnisse
wurden mittels Cohens kappa () und prozentualer bereinstimmung (PA) ausgewertet. Ergebnisse: Die Untersucher fanden 40 bzw. 41% positive NRP (PI > 0): Arzt: 155, Student: 157,
mit leichter Bevorzugung der linken Seite (1,2:1). Beide Untersucher konnten Patienten mit >6 positiven NRP gleich gut identifizieren (12 vs. 13 Patienten). Die -Werte bezogen auf die einzelnen Punkte waren hoch bis sehr hoch und reichten von 0,52
bis 0,95. Der -Wert fr alle positiven NRP war sehr hoch mit
= 0,80 fr die linke und hoch mit = 0,74 fr die rechte Seite.
Der PA lag zwischen 78,1% und 96,9%. Die hchsten bereinstimmungen fanden sich bei NRP C0, NRP C2 und NRP C7. Die
Reproduzierbarkeit wurde weder von Alter, Geschlecht, Body
Mass Index noch der Erfahrung des Untersuchers beeinflusst.
Schlussfolgerung: Die hohe Reproduzierbarkeit bei weiblichen
Patienten spricht fr eine klinische Bedeutung der NRP.
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Keywords
Cervical pain Muscular trigger points
Neuroreflectory changes Dental focus Neural therapy
Fig. 1. Examination of neck reflex points (NRP): the C1 NRP region (left photo) and the C7 NRP region (right photo) are investigated for tenderness or pain by
palpation. Details of the test performance are described in the Methods section, see also [7]. Dr. S. Weinschenk 2009.
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Introduction
Statistical Analysis
The association between NRP and demographic background variables was
assessed through Kendalls Tau. We also applied Cohens kappa coefficient ()
for a detailed analysis. The coefficient is an appropriate and frequently used
measure of inter-rater agreement in diagnostics and medical examination procedures [11]. A value of 0.20 is considered to be an indicator of poor reliability, 0.40 as slight, 0.60 as moderate, 0.80 as good, and >0.80 as very
reliable [12].
The coefficient was assessed for its statistical significance through a hypothesis test. To examine the probability of detecting a significant coefficient,
PI = 0
PI = 1
PI = 2
PI= 1 or 2
Right side
Physician
Student
Physician
Student
106
59
27
86
102
60
30
90
123
43
26
69
125
44
23
67
a sample size calculation was performed. According to Myburgh et al. [13] and
Bron et al. [14], the minimum acceptable value was set to 60 for 2 raters and 2
possible ratings. Alpha () was set to 0.05 and beta () to 0.20. The results of
power analysis showed that a of 0.60 could be achieved with a sample size of
n=18. Thus, the sample size of the present study was sufficient.
To compare the results of the present study with the findings on mTrP examination reproducibility [14], we also calculated the pair-wise percentage of
inter-rater agreement (PA). According to [11], the PA is defined as the ratio of
the number of agreements to the total number of ratings made.
Results
Patients Characteristics
Consecutive patients (n=32) with chronic neck pain persisting
for 632 months were included in this study. The median age of
subjects was 51.9 years (SD = 12.5, range 2675 years). Median
body mass index (BMI) was 22.6 kg/m2 (SD = 3.4, range 17.4
33.1kg/m2); 29 patients (90.6%) were female. The study population
represented the average gender and age profile of patients in the
outpatient practice affiliated with the obstetrics and gynecology
practice in which the study was conducted.
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Left side
PI = 0
PI = 1
PI = 2
Right side
Agree
Disagree
Agree
Disagree
98
41
20
18
22
8
0.83
0.72
0.81
111
31
19
20
22
8
0.81
0.67
0.81
PI = pain intensity, tenderness of the NRP given by the patient (0 = no tenderness, 1 = moderate
tenderness, 2 = marked tenderness/pain); = Kappa coefficient ( values).
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Fig. 3. Positive NRP (PI>0) at different levels of NRP (C0C7) for the left
and right side of the cervical region. At each single NRP, there is no difference
between the findings of the 2 examiners.
Table 3. Inter-rater agreement: and percentage of agreement for each of the
2x6 NRP (left and right side)
NRP
Left side
Left side PA
Right side
Right side PA
C0
C1
C2
C3
C4
C7
C0C7
0.78
0.64
0.95
0.81
0.72
0.89
0.80
93.8
78.1
96.9
87.5
87.5
93.8
89.6
0.52
0.75
0.90
0.75
0.72
0.63
0.74
90.6
87.5
93.8
84.4
87.5
81.3
87.5
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Table 4. Correlation of NRP examination with patients age, gender, height, weight, and BMIa
Left
Physician
Age
Genderc
Height
Weight
BMI
Student
Age
Genderc
Height
Weight
BMI
Medianb
Right
Median
C0
C1
C2
C3
C4
C7
C0C7
C0
C1
C2
C3
C4
C7
C0C7
0.22
0.15
0.17
0.23
0.19
0.05
0.31
0.03
0.07
0.08
0.02
0.09
0.01
0.00
0.02
0.04
0.02
0.15
0.25
0.21
0.02
0.01
0.06
0.08
0.08
0.19
0.09
0.10
0.04
0.00
0.03
0.09
0.05
0.04
0.04
0.11
0.12
0.07
0.14
0.13
0.24
0.24
0.17
0.07
0.12
0.18
0.27
0.15
0.22
0.21
0.18
0.04
0.04
0.09
0.05
0.15
0.01
0.06
0.10
0.13
0.07
0.25
0.11
0.07
0.14
0.16
0.18
0.01
0.09
0.13
0.19
0.12
0.15
0.28
0.27
0.14
0.34
0.06
0.09
0.08
0.01
0.10
0.07
0.02
0.04
0.04
0.09
0.03
0.15
0.11
0.06
0.19
0.07
0.13
0.18
0.18
0.11
0.06
0.13
0.09
0.05
0.11
0.05
0.06
0.02
0.34*
0.10
0.03
0.10
0.15
0.21
0.22
0.27
0.09
0.18
0.14
0.27
0.11
0.23
0.24
0.20
0.08
0.04
0.03
0.01
0.02
0.22
0.08
0.18
0.21
0.02
0.19
0.13
0.10
0.17
0.14
0.21
0.04
0.10
0.16
Discussion
This is the first study to demonstrate that tenderness of specific
soft tissue of the cervical spine, so called NRP, is detectable with a
very high reproducibility. In this randomized and blinded study,
we found a strong agreement for NRP examination between 2 independent and blinded examiners. Our results suggest that NRP
can be detected independently of the patients characteristics and
the examiners experience.
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bThe
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(table3), whereas all other NRP showed good or very good interrater reliability. The neck anatomy at different cervical levels may
explain the difference in reproducibility of the NRP. NRP C0 is
palpated at the bone of the occipital protuberance, whereas all
other NRP are located in the soft tissue of the cervical neck. Tenderness of the periosteum may be a neurophysiological entity that
is different from tender soft tissue.
The correlation of the examiners findings was not significantly
influenced by biometric factors such as patients age, gender, or
BMI. We found a weak, but not significant negative correlation to
BMI. The assumption that a thicker neck may reduce the palpation
precision of NRP is possible, but not derivable from our data.
Although there was a slight prevalence for left sided NRP
(fig.3), the side of the cervical spine examined did not influence
results obtained by the examiners (table3). This indicates that NRP
can be examined bilaterally with a high reliability.
Acknowledgements
Conclusion
The high reproducibility of NRP speaks for a potential clinical
relevance: they may correlate with chronic silent inflammation
sites of the visceral cranium, which adversely influence the neck
region. NRP present a foundation on which to develop new therapeutic approaches for patients with chronic neck and shoulder
pain. First clinical observations in our institution with therapeutic
local anesthesia reinforce these assumptions [6]. Our results provide a rationale for further studies on the clinical relevance of NRP,
their neuroanatomical base, and new therapeutic options for patients with chronic pain disorders.
The authors would like to thank the patients of the outpatient practice in
Karlsruhe who participated in this study. We also thank Christina Armstrong,
Heidelberg, for her excellent help in the English translation, and Pia Hofheinz,
M.Sc., for her brilliant technical assistance.
Disclosure Statement
This study was neither sponsored nor funded. The authors declare no conflict of interest.
References
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