Manual Therapy 15 (2010) 490e495

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Manual Therapy
journal homepage: www.elsevier.com/math

Original article

Reliability and validity of head posture assessment by observation and

a four-category scale
Anabela G. Silva a, b, c,1, *, T. David Punt a, c,1, Mark I. Johnson a, c,1
a
Faculty of Health, Leeds Metropolitan University, Civic Quarter, Leeds LS1 3HE, United Kingdom
b
School of Health, University of Aveiro, Campo Universitário de Santiago, 3810-193 Aveiro, Portugal
c
Leeds Pallium Research Group, United Kingdom

a r t i c l e i n f o a b s t r a c t

Article history: Head posture (HP) is assessed as part of the clinical examination of patients with neck pain using
Received 31 October 2009 observation and qualitative descriptors. In research, HP is characterised through the measurement of
Received in revised form angles and distances between anatomical landmarks. This study investigated whether the assessment of
27 April 2010
HP as performed in clinical practice is reliable and valid. Ten physiotherapists assessed forward HP, head
Accepted 5 May 2010
extension and side-flexion from images of 40 individuals with and without previous experience of neck
pain using a four-category scale. The assessment was repeated twice with a 1-week gap. Physiothera-
Keywords:
pists’ ratings were then compared with angular measurements of the same components of HP. K values
Head posture
Observation
for intra-rater reliability varied between 0.22 and 0.81 for forward HP, between 0.19 and 0.69 for head
Reliability extension and between 0.38 and 0.67 for side-flexion. K values for inter-rater reliability were 0.02 for
Validity forward HP, 0.07 for head extension and 0.19 for side-flexion. Correlation coefficients between the ratings
and the angular measurements varied between
0.16 and
0.49 for forward HP, between
0.17 and 0.68
for head extension and between
0.04 and 0.37 for side-flexion. The assessment of HP by observation
and a four-category scale showed poor reliability and validity.
Ó 2010 Elsevier Ltd. All rights reserved.

1. Introduction
Head posture (HP) assessment is recommended as part of the
examination of patients with neck pain (NP) to aid diagnosis,
determine treatment strategies and monitor the progress of the
patient (American Physical Therapy Association, 2001; Kendall
et al., 2005; Petty, 2006; Lau et al., 2008; Magee, 2008; Yip et al.,
2008). This is based on evidence that deviations in HP are associ-
ated with decreasing length moment arms and increasing activity
of the neck extensors (Kumar et al., 2002; Przybyla et al., 2006),
increasing forces acting on anatomical structures (Bonney and
Corlett, 2002) and decreasing range of movement of the neck
(Edmondston et al., 2005). Studies have shown that patients with
neck pain have decreased range of motion of the neck (Woodhouse
and Vasseljen, 2008), reduced neck muscle strength, neuromus-
cular efficiency and endurance (Harris et al., 2005; Cagnie et al.,
* Corresponding author. Escola Superior de Saúde, Universidade de Aveiro,
Campo Universitário de Santiago, 3810-193 Aveiro, Portugal. Tel.: þ351
234401558x23899; fax: þ351 234401597.
E-mail address: asilva@ua.pt (A.G. Silva).
1
www.leeds.ac.uk/pallium
2007; Johnston et al., 2008) and greater neck muscle fatigability
(Falla et al., 2003).
A recent systematic review of studies comparing HP in indi-
viduals with NP and asymptomatic individuals was inconclusive
due to conflicting outcomes and shortcomings in methodological
quality of the included studies (Silva et al., 2010).
However, the more recent studies included in this systematic
review are of better methodological quality and suggest that there
is a difference in HP between patients with NP and asymptomatic
participants. For example, there were 10 studies that measured
forward HP in adults, of which 4 reported a difference and 6 did not.
Five out of these 6 studies were judged as using a small sample size
and, therefore, are likely to be reporting a false negative. In contrast,
3 of the 4 studies that reported a difference in HP between patients
and asymptomatic participants used an a priori sample size
calculation. Moreover, two of these studies (Lau et al., 2008; Yip
et al., 2008) measured the angle C7-tragus-horizontal as an indi-
cator of HP while participants were in static standing and reported
a mean difference of 5.1 and 6.7, respectively. These values are
higher than the standard error of measurement calculated by Lau
et al. (2008) in the same study (1.2 ) suggesting that the differ-
ence in HP between patients with NP and asymptomatic partici-
pants is clinically significant.

1356-689X/$ e see front matter Ó 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.math.2010.05.002
 A.G. Silva et al. / Manual Therapy 15 (2010) 490e495
Physiotherapists report that they routinely assess components
of HP such as forward HP, side-flexion, extension, flexion and
rotation, for patients with NP (Silva et al., 2009a). They do this by
observing HP against an imaginary line of reference and using
qualitative descriptors to characterise HP. However, the use of HP
evaluation to inform the management of patients with NP requires
that clinicians are able to accurately and consistently assess HP.
Studies on the reliability of HP assessment by observation show
conflicting results with some reporting that it is reliable (Griegel-
Morris et al., 1992; Paternostro-Sluga et al., 1995; Eriksson et al.,
2000) and others that it is not (Cleland et al., 2006). However, the
small sample of subjects (n ¼ 10) (Griegel-Morris et al., 1992) and
raters used (n ¼ 2) (Eriksson et al., 2000) and the use of statistics
that do not correct for the agreement expected by chance
(Paternostro-Sluga et al., 1995) could have inflated the results of
these studies.
To date, no study has investigated the validity of assessing HP by
observation and severity scales. In research, HP has been charac-
terised by measuring angles or distances between anatomical
landmarks in the head and neck (Raine and Twomey, 1997). For
example, the angle C7-tragus-horizontal is usually used to char-
acterise forward HP and the angle tragus-eye-horizontal to char-
acterise head extension (Raine and Twomey, 1997). These
measurements have been found to be reliable and valid when
compared to measurements taken using radiographs (van Niekerk
et al., 2008). Therefore, a way of testing the validity of assessing HP
through observation and severity scales is to directly compare
clinical assessments of HP with measurements of angles indicative
of components of HP. The aim of this study was to assess inter- and
intra-rater reliability and concurrent validity of HP assessment
through observation and a severity scale.
2. Methods
Ethical approval to conduct the study was obtained from the
Service of Bioethics and Medical Ethics (Portugal) and from the
Research Ethics Sub-Committee of the Faculty of Health at Leeds
Metropolitan University (England).
2.1. Individuals and raters
2.1.1. Individuals
Images of the trunk and head were taken from 40 individuals,
recruited from the general population using notice board
advertisements or by word of mouth. The sample size was
informed by the findings of Altaye et al. (2001) for a minimal
expected level of reliability of 0.6, when power is set at 80% and
alpha at 5%. Eligibility criteria were being able to stand without
help in front of the cameras and to be 18 years or older. Indi-
viduals were asked about previous experience of NP. However, it
was considered that the ability of physiotherapists to consistently
and accurately rate HP should be independent of the presence of
pain if they are expected to be able to detect differences in HP
due to treatment as the patient progresses from a stage of pain to
a stage of no pain.
2.1.2. Raters
Raters were 10 physiotherapists recruited using advertisements
and word of mouth from physiotherapists that had an association
with Aveiro’s University (Portugal) or Leeds Metropolitan Univer-
sity (UK). Eligibility criteria were having at least 3 years of clinical
experience and to self-report that they routinely assess HP by
observation in their clinical practice.
491
2.2. Procedures
2.2.1. Determining anatomical angles of components of HP
One frontal and one lateral images of each individual were
collected using two video cameras and manually digitised by the
principal investigator (AS) to calculate 3 angles: (1) C7-tragus-
horizontal, indicative of forward HP, (2) tragus-eye-horizontal,
indicative of head extension (positive values) or head flexion
(negative values) and (3) right eareleft ear-horizontal, indicative of
side-flexion with 0 indicating perfect symmetry. Rotation of the
head was not assessed because the angular measurements of head
rotation are easily contaminated by trunk rotation (Norkin and
White, 1995). The detailed methods of image acquisition and digi-
tisation are described elsewhere (Silva et al., 2009b). AS was blind
to the qualitative assessment of HP made by the raters and the
digitisation procedure was found to be highly reliable (ICCs  0.98)
(Silva et al., 2009b).
2.2.2. Image rating
The same set of 40 images was rated by 5 Portuguese raters
and by 5 British raters using identical procedures. Images were
presented using a Power Point slide presentation (Figure 1). Raters
were given standardised written instructions, the answer sheet
and an envelope. In the instructions sheet, raters were asked to
rate forward HP and extension from the lateral image and side-
flexion from the frontal image using a four-category severity scale
(1: normal, 2: slight deviation, 3: moderate deviation and 4:
severe deviation). This scale was chosen because it was found to
be used in clinical practice to characterise HP (Silva et al., 2008).
Raters were told to view each image only once, to not change their
assessment after moving to the next image and to not give any
information related to their assessment to AS. Raters were then
shown the images and recorded their assessment on the answer
sheet. At the end of the assessment they placed the answer sheet
in the envelope, and gave it sealed to AS. The envelope was kept
sealed until assessments had been completed by all physiothera-
pists. No external references were used to aid the assessment
because in a previous study physiotherapists reported not to use
external aids to inform the assessment of HP by observation (Silva
et al., 2009a).
Each rater repeated the assessment one week later. The order of
appearance of the images was randomised for assessment 1 and
again for assessment 2 to minimise any learning or order effects.
Each rater was blind to the assessment made by others.
Fig. 1. Images from one participant in the study: (A) frontal image and (B) lateral
image (participant consent is available on request). Note: in the study the images were
shown without masking the eyes.
492 A.G. Silva et al. / Manual Therapy 15 (2010) 490e495

2.3. Data analysis Table 2

Percentage of agreement among the 10 raters and number of images that received 2,
3 and 4 different ratings.
Percentage of agreement, confidence intervals and the standard
error of the mean were calculated for intra- and inter-rater reli- Forward Extension Side-flexion
HP
ability. Weighted Cohen’s K coefficients were also calculated for
intra-rater reliability using an online calculator (VassarStats, Vassar Number of images that received 1 0 (0%) 0 (0%) 1 (2.5%)
rating (% of agreement)
College, Poughkeepsie, NY, USA). A multirater K was calculated for
Number of images that received 2 4 (10%) 10 (25%) 23 (57.5%)
inter-rater reliability using the SPSS syntax MKAPPASC.SPS and different ratings
data from the first assessment. An a priori level of acceptable reli- Number of images that received 3 17 (42.5%) 18 (45%) 16 (40%)
ability was set for a K of 0.6 or a percentage of agreement of 80% different ratings
(Walter et al., 1998). Number of images that received 4 19 (47.5%) 12 (30%) 0 (0%)
different ratings
Angular values were grouped according to the rating attributed
by all raters in the first assessment and analysed using descriptive
statistics. Angular values and the ratings attributed by each rater
were also correlated using the Kendall’s Tau b correlation coeffi- discrepancy among results. Weighted K values varied between
cient and interpreted using criteria suggested by Pett (1997): 0.22 and 0.81 for forward HP, between 0.19 and 0.69 for head
0.00e0.29 weak, 0.30e0.49 low, 0.50e0.69 moderate, 0.70e0.89 extension and between 0.38 and 0.67 for side-flexion. Nine out of
strong, 0.90e1.00 very strong. 10 raters showed K values below 0.6 for forward HP and extension
(Table 1). For side-flexion, 4/10 raters showed a K value above 0.6.
However, the lower end of the 95% CI was below 0.6, suggesting
3. Results
that in future assessments the intra-rater reliability may be less
than acceptable.
3.1. Individuals

Forty individuals had their image taken (21 women and 19 men;
mean  SD age 39.50  14.18 years, age range 20e65 years;
mean  SD weight 69.73  14.81 kg and height 164.35  9.14 cm).
Sixteen of these individuals reported that they had previous
experience of NP but no episode lasted longer than 3 days. Only 1
was in pain when the images were taken.
3.2. Raters
The 40 sets of images were assessed by 10 physiotherapists (5
Portuguese and 5 British) ranging in age from 28 to 41 years and
a mean of 12.7 years of clinical experience (range: 7e24). Two were
full-time clinicians, 2 were full-time University lecturers who
taught HP assessment and 6 worked as both clinicians and
University lecturers. Three raters reported to use the scale used in
this study in clinical practice (referred as raters 1, 3 and 6).
3.3. Intra-rater reliability
When assessing the same image on 2 occasions separated by 7
days, 7/10 raters for forward HP and 9/10 raters for head extension
and side-flexion scored the same category on the scale for the
same image in both assessments for less than 80% of the 40 images
(Table 1). Raters used different number of scale categories and, as
would be expected, raters using fewer categories tended to show
higher percentages of agreement. This may help explain the
3.4. Inter-rater reliability
When presented with the same images on the first assessment and
using a four-category scale, the 10 raters scored at least 3 different
categories of assessment for 90% of the 40 images for forward HP, 75%
for head extension and 40% for side-flexion (Table 2). No image
received the same rating from all raters for forward HP and extension
and only 2.5% (n ¼ 1) received the same rating for side-flexion. The
multirater K calculated for the 10 raters was 0.02 for forward HP, 0.07
for head extension and 0.19 for side-flexion, indicating that agree-
ment among the 10 raters was not very different from that expected
by chance alone (Table 3). Results also show that Portuguese and
British raters had similar levels of inter-rater reliability suggesting
that potential differences in the theoretical and clinical background of
the physiotherapists did not affect the reliability levels. Furthermore,
previous experience using the scale to assess HP in clinical practice
did not contribute to higher levels of inter-rater reliability.
3.5. Angular measurements
The angle C7-tragus-horizontal is used as indicative of forward
HP and decreasing values are indicative of a more forward HP. Mean
(SD) angular values were 46.62  6.10 (range: 33.76e57.77 ). The
angle tragus-eye-horizontal is used as indicative of head extension
and increasing values are indicative of a more extended head. Mean
(SD) angular values were 18.11  7.75 (range:
1.36 to 36.08 ).

Table 1
Percentage of agreement, K values, 95% confidence interval (95% CI) and standard error (SE) for intra-rater reliability.

Rater Forward HP Extension Side-flexion

% Agreement K CI SE % Agreement K CI SE % Agreement K CI SE

1 7.5 0.23 0.05e0.40 0.09 75 0.69 0.50e0.89 0.10 65 0.67 0.49e0.84 0.09
2 47.5 0.34 0.12e0.56 0.11 47.5 0.19 0.00e0.45 0.13 42.5 0.38 0.20e0.55 0.09
3 40 0.42 0.26e0.59 0.09 45 0.31 0.07e0.56 0.12 75 0.64 0.43e0.85 0.11
4 80 0.22 0.00e0.60 0.19 87.5 0.25 0.00e0.67 0.21 67.5 0.43 0.18e0.68 0.13
5 55 0.42 0.23e0.61 0.10 45 0.22 0.00e0.60 0.19 60 0.43 0.21e0.65 0.11
6 67.5 0.45 0.20e0.70 0.13 72.5 0.51 0.29e0.72 0.11 77.5 0.54 0.30e0.79 0.13
7 85 0.81 0.67e0.95 0.07 57.5 0.23 0.0e0.50 0.14 80 0.62 0.41e0.83 0.11
8 42.5 0.28 0.09e0.47 0.10 47.5 0.27 0.13e0.41 0.07 62.5 0.45 0.22e0.67 0.12
9 75 0.52 0.29e0.75 0.12 75 0.56 0.32e0.80 0.12 70 0.43 0.20e0.66 0.12
10 80 0.48 0.19e0.77 0.15 77.5 0.48 0.19e0.77 0.15 70 0.63 0.44e0.83 0.10
 A.G. Silva et al. / Manual Therapy 15 (2010) 490e495 493

Table 3
K values, 95% confidence interval (95% CI) and standard error (SE) for inter-rater reliability (calculated using data from the first assessment).

Raters N Forward HP Extension Side-flexion

K CI SE K CI SE K CI SE
All raters 10 0.02 0e0.06 0.02 0.07 0.03e0.11 0.02 0.19 0.15e0.23 0.02
Portuguese 5 0.00 0e0.06 0.03 0.05 0e0.11 0.03 0.09 0.01e0.17 0.04
raters
British raters 5 0.00 0e0.08 0.04 0.08 0e0.18 0.05 0.38 0.28e0.48 0.05
Raters using the 3 0.02 0e0.16 0.07 0.11 0e0.25 0.07 0.03 0e0.17 0.07
scale in clinical
practice

The angle right eareleft ear-horizontal is used as indicative of side-
flexion with 0 indicating perfect symmetry. Mean (SD) angular
values for this angle were 1.56  3.03 (range: 0.02e7.6 ).
3.6. Relationship between the angular measurements and the
severity scale categories
Matching the angular values against the respective category scored
by the raters in the first assessment, revealed no clear correspondence
between each one of the categories of the scale and an interval of
angular values for any of the 3 angles measured (Table 4). Mean
angular values within each category tend to decrease from category 1
to category 4 for forward HP suggesting that individuals with more
forward HP were correctly scored a category of higher severity.
However, minimum values were the same for the 4 categories and
maximum values differ less than 2 among the 4 categories and
standard deviation also showed that categories overlap considerably.
Mean angular values within each category tend to increase from
category 1 to category 4 for extension and side-flexion suggesting that
individuals with a more extended and side-flexed head were correctly
scored a category of higher severity. However, and as for forward HP,
minimums, maximums, means and SDs show that categories overlap
considerably and, therefore, suggest that raters were unable to accu-
rately attribute a higher rating to more deviated HPs.
Correlation coefficients between angles and ratings attributed
by each one of the 10 raters varied between
0.16 and
0.49 for
forward HP, between
0.17 and 0.68 for head extension and
between
0.04 and 0.37 for side-flexion (Table 5). This indicates
weak to low correlation between angular measurements and the
severity ratings for forward HP and side-flexion and weak to
moderate correlation for head extension.
4. Discussion
The assessment of forward HP, head extension and side-flexion
by observation and a four-category scale seems to be neither reli-
able nor valid. This challenges the clinical usefulness of using
observation to assess HP, in particular, considering that mean
differences between individuals with and without NP for HP are
likely to be small. A systematic review of studies comparing HP
between individuals with and without NP found that mean differ-
ences between groups varied between 2.2 and 6.7 (Silva et al.,
2010). This suggests that differences within and between patients
with NP are likely to be of similar magnitude, but the results of this
study challenge the ability of physiotherapists to accurately and
consistently assess such differences.
Factors such as the subjectivity of the scale categories requiring
a judgement from the rater and the possibility that the patterns of
reference used when rating HP varied within and between raters
may have contributed to the low reliability. This is supported by the
findings of a previous study where the relevance attached to HP
deviations was found to vary among physiotherapists (Silva et al.,
2008). It is also possible that the pattern being used changed for
the same rater between assessments or throughout the assessment
as a result of comparing HP between the individuals in the images.
Furthermore, the level of reliability among the raters that used the
scale in clinical practice was not higher than the level of reliability
among those that did not, suggesting that lack of experience with
the scale was not responsible for the low levels of reliability.
In clinical practice, physiotherapists usually assess HP after
taking the history of the patient, while in the present study they
were blind to participants’ status (patient with NP or asymptomatic).
However, knowledge of the patient history does not seem to have an
impact on the level of reliability of other clinical tests used to assess
neck range of motion, tenderness, atrophy, sensitivity to pain and
strength (Bertilson et al., 2001). A further consideration is whether
the fact that raters were not in the presence of participants but
assessing photographs that only showed the upper half of the indi-
viduals being assessed could have affected the reliability and validity
of the assessment. Photographs were chosen because it was a means
to standardise HP so that the same posture was shown to all raters in
the first and second assessments 1 week apart, and to allow the
comparison between the observational assessment and the angular
measurements. In addition, photographs were also reported to be

Table 4
Descriptive statistics for angular values grouped according to the category of the scale attributed to each component of HP by all raters.

Scale category Normal Slight deviation Moderate deviation Severe deviation

C7-tragus-horizontal/forward HP
Number of ratings 136 126 89 49
Range of values 33.76e57.77 33.76e57.77 33.76e57.26 33.76e56.28
Mean  SD 48.13  5.95 47.92  5.59 44.71  5.35 42.55  5.44

Tragus-eye-horizontal/extension
Number of ratings 160 142 82 16
Range of values
1.36 to 30.79
1.36 to 36.08
1.36 to 36.08 15.08e36.08
Mean  SD 16.06  6.32 18.04  7.81 20.43  7.92 27.11  7.07

Right eareleft ear-horizontal/side-flexion

Number of ratings 167 165 57 11
Range of values 0.02e7.6 0.02e7.6 0.02e6.13 0.18e6.13
Mean  SD 2.44  1.91 2.93  1.83 3.22  2.00 3.28  2.6
494 A.G. Silva et al. / Manual Therapy 15 (2010) 490e495

Table 5 increased the levels of reliability (van Genderen et al., 2003). Other
Correlation between the ratings attributed by the raters and the angular values used factors that could have negatively affected the reliability were the
as surrogate measures for each component of HP.
use of half body photographs and the use of HP assessment out of
Rater Forward HP Extension Side-flexion the clinical practice context. Physiotherapists use imaginary lines of
T p T p T p reference (e.g. line of gravity) to inform their assessment of HP
1
0.39 0.002* 0.68 0.000* 0.28 0.024* (Silva et al., 2009a) which cross anatomical points in the head,
2
0.37 0.003* 0.27 0.035* 0.04 0.730 thorax and lower limbs. However, in this study some reference
3
0.44 0.000* 0.42 0.000* 0.15 0.228 points were missing as only half body (head to waist) photographs
4
0.16 0.233 0.39 0.004*
0.04 0.779
were used which may have affected their ability to make judgments
5
0.48 0.000* 0.19 0.131 0.37 0.004*
6
0.41 0.001* 0.33 0.01*
0.02 0.857
on HP. In addition, HP is usually considered in the context of the
7
0.49 0.000* 0.19 0.152 0.09 0.467 whole examination and knowledge of whether HP influences pain
8
0.49 0.000* 0.53 0.000* 0.16 0.201 or pain influences HP is perhaps considered when assessing the
9
0.21 0.110 0.24 0.060 0.07 0.574 patient. It is possible though that this information can affect the
10
0.18 0.171
0.17 0.206 0.05 0.682
reliability of HP assessment.
T, Tau b correlation coefficient; *, statistically significant. The lack of reliability and validity of HP assessment by obser-
vation and the small size of the differences in HP between partic-
used in clinical practice and assessed by observation by 19.6% of the ipants with and without NP suggest that future studies should
respondents in a previous study (Silva et al., 2009a). explore the reliability and validity of quantitative procedures of HP
The low reliability found in the current study is in agreement assessment that could easily be used in clinical practice.
with the findings of Cleland et al. (2006), but contrast with the
findings of Griegel-Morris et al. (1992), Paternostro-Sluga et al. 5. Conclusion
(1995) and Eriksson et al. (2000). It could be expected that differ-
ences in the current study procedures such as the use of a scale The assessment of HP through observation and the use of a four-
with more categories, use of photographs, absence of a pre-training category severity scale seem to be neither reliable nor valid chal-
session might have contributed to the contrasting results. However, lenging its clinical usefulness.
in the study of Cleland et al. (2006) the assessment of forward HP
was dichotomized as present or absent, carried out in the presence Acknowledgements
of the patients and experienced physiotherapists received pre-
study training. Nevertheless, Cleland et al. (2006) also reported HP This work was funded via a PhD scholarship from the Founda-
assessment to be unreliable. Therefore, it is likely that factors such tion for Science and Technology (SFRH/BD/30735/2006), Portugal.
as the use of a low number of individuals (n ¼ 5 for inter-rater
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