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