Clinical Tests for the Lumbar Spine
John Doyle
Physiotherapy Learning & Development Manager, Nuffield Health
Extended Scope Physiotherapist, Frimley Health NHS Trust
@JPTDoyle
Thou shouldst say to [the patient]: ‘Extend now thy two legs and contract both again.’ When he extends them he contracts them both immediately because of the pain he causes in the vertebra of his spinal column in which he suffers
van Middendorp (2010) Eur Spine J
One who has a wrenching strain in the vertebral column of his lower back, this is a medical condition I can treat van Middendorp (2010) Eur Spine J
Are we any better than the ancient Egyptians at figuring out back pain?
We definitely know more than the Ancient Egyptians about …
Pathology
Epidemiology
Pain
Diagnostic Imaging
Statistics
And we definitely have more clinical tests…
162% increase in prevalence between 1992 and 2006
Days of sick certification
1950 1960 1970 19800
1000
2000
MaleFemale
Waddell 1987
Back pain has always existed
Disability has not!
For most serious pathology clinical tests are of questionable value
Subjective questions are more valuable for screening
Neurological examination
Baseline assessment
Onward referral
Fairbank et al (2011) Evid Based Spine Care JHenscke et al (2013) Cochrane Database of Systematic Reviews
Spinal Stenosis
Study performed in tertiary referral centre
Patients quite likely to have spinal stenosis
Index of suspicion
Abnormal Neurological Examination
Abnormal Romberg
Test
Treadmill Test
Wide Based Gait
Index of suspicion
Sign +ve LR -ve LRAbsent Achilles Reflex 2.8 0.58
Decreased Pin Prick Sensation 2.5 0.90
Decreased Vibration Sense 2.1 0.69
Muscle Weakness 2.1 0.68
Abnormal Romberg Test 4.3 0.67
Earlier Onset Of Symptoms: Flat Treadmill
4.0 0.39
Longer Total Walking Time: Inclined Treadmill
6.3 0.54
Wide Based Gait 14 0.59
De Schepper et al (2013) Spine
Lumbar Disc Herniation & Radiculopathy
Index of suspicion
Pain on Palpation
Abnormal Neurological Examination
Straight Leg Raise
Crossed Straight Leg
Raise
Index of suspicion
Sign Sensitivity SpecificityBell Test (palpation) 0.49 0.63
Straight Leg Raise 0.92 0.28
Crossed Straight Leg Raise 0.28 0.90
Van der Windt et al. Cochrane Database of Systematic Reviews 2010
Possibly the SIJ
Maybe the disc
Probably not the facet joints
Compression
Sacral Thrust
Gaenslen
Thigh ThrustDistraction
Laslett et al 2005 Manual Therapy
Index of suspicion
Sign +ve LR -ve LROne positive test 1.78 0.00
Two positive tests 2.73 0.10
Three positive tests 4.29 0.80
Four positive tests 3.20 0.49
Five positive tests 2.13 0.84
Laslett et al 2005 Manual Therapy
Sensitivity Specificity
0.38 0.89
Centralisation of symptoms on repeated movements in the diagnosis of disc pain
But…..What if there are no peripheral symptoms???
Hancock et al 2007 Eur Spine J
Can you differentiate between disc/ facet joint pain? Does it matter?So What?!?!
Not just pathoanatomical focus
Pain mechanisms approach
Understand all contributing factors
‘Don’t have any faith really, what I want to find out is what is causing the pain all through my body and Iseem to meet a blank wall’
‘My back was hurting. I tell the doctor what’s up. And he still won’t examine me to see if I’m telling the truth or not you can’t fix a car just by looking at it’
‘Being believed is the
mostImportant’
Palpation Neurological Assessment
Range of Motion Testing
Functional DemoMuscle Testing
Strength and endurance deficits exist in some patients with low back
pain
? Relevance of test position and contraction
type?
Simple baseline of patients exercise
capacity?
Patients able to perform at least a 60 second hold on
Biering-Sorensen endurance test
Is the best ‘clinical test’ done with a pen?
Pain Function Distress
Return To Work
Fear Avoidance
I’m a MckenzoidCombined
Movement Theory For All!!!
We Want Cognitive Functional Therapy!!
Are we any better than the ancient Egyptians at figuring out back pain?
Yes! But only if we take a wider
thinking approach to the patient
Can you differentiate between disc/ facet joint pain? Does it matter?
To be better than the ancient Egyptians
Think pain mechanisms not just tissues
Understand the contributing factors
Try to understand the value of tests
Use a variety of relevent tests to understand your patients function & disability
Understand the contributing factors
One who has a wrenching strain in the vertebral column of his lower back, this is a medical condition I can treat
Treatment:You must lay him stretched out/prostrate and prepare for him...
van Middendorp (2010) Eur Spine J
Can you differentiate between disc/ facet joint pain? Does it matter?Thanks!
#Therapyexpo
@JPTDoyle
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